HomeMy WebLinkAbout0015 SHOREY ROAD - Health 15 SHOREY ROAD, HYANNIS
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TOWN OF BARNSTABLE
LOCATION 1 •57//G/e1E L/ eJ SEWAGE# S'0—2
VILLAGE ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / if�#L
LEACHING FACILITY: (type) O/T (size) o o 4<,1<
NO.OF BEDROOMS
BUILDER OR OWNER 11.L£N
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland.and Leaching Facility(If any wetlands exist
within 300 feet of leaching faciliw Feet
Furnished by `r�r
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TOWN OF BARNS TABLE
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LOCATION f f SVo� ,. SEWAGE # I, 1
VIL VAGE W, ( G\A�S r 'i kSSESSOR'S MAP & LOT 47° Q
.INSTALLER'S NAME & PHONE NO. 9 & B CANCO 775-6264
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY:(type) LMq. l 1 (size) 10 00
NO. OF BEDROOMS h ,PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 'Active R
DATE PERMIT ISSUED: °' '
DATE COMPLIANCE,ISSUED:
VARIANCE GRANTED: Yes No /✓'
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Apr ira i rt u 14ri tit a 1 lVn Its Tomitrnrtiun rani#
Appli tion i e eby made for a PermitAt.Tco9i V uct ( ) or Repair ( L,<`an Individual Sewage Disposal
System at
1 ..-�.S-�S'/7�� -----../2z........_... .._..l)r. ........., y %'.s...........................................................
3-
Lo atio Address t No.
tfe�------------------------------------------- � '�e��,%�• .. ....... � G..�r.,��
l
:.
Owner _
l9_r�1 Gv....••••--•••-•-••--•••••..:••-••••-••---••--•-••.............•-•...... --_ p ------mlo !2. Ada J `--... :.1' .........
Installer Address T
Q Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms______________13 . _. _Expansion Attic Garbage Grinder
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.,.......................................
,-]
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-•--•-•-••-----------------•-•••----••-•-•----•--••----••••••••--•----•-•-•••-••-•.........---••-•---•----•--••.......-•-••••-•............................
0 Description of Soil..:'-....................................................................................................................................................................
W
U ature of Repairs or Alterations—Answer wher,�applicable.._Z-n.Ji4.Lf_------_-1 .....1.0_0.0-_--_-?_ (& ._....
I
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 b e s d by e board of health.
Signed ............................... ................... .... ..... � +
Date
Application Approved By ......:....... : ...... ........ .. ................................el- I-�'�
.. r.:.._........---....---•-.............................. ate ....... .
Application Disapproved for the following reasons: .............................................................................................. .. ................................
..........................................
PermitNo. --- ------- ---------------- -----------------------------------------------------------------------------------------------
I oat
-------
��.. ..... :..... Issued .....,...... ........ ..'...F. r ......
Date
67
No.. 'f.•~' / Fimic ..3.d..............
+ THE COMMONWEALTH OF-MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
ILc� , pphration for Diripwial Worlm Tomitrnnrtion V ermit
t �j y,
Application is hereby made for a Permit to Coil�truct ( .) or Repair ( an Individual Sewage Disposal
System at
� ,.� 1r _� ...........................................................
Lication-Address- or of No.
10
Opener a ( Address
Installer Address
Type of Building Size Lot____________________ q. feet
t t Dwelling— No. of Bedrooms--------------13------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons-__._______________________ ,Showers ( ) — Cafeteria ( )
dOther fixtures -----•-_-----------------..............................................._•-------------
W Design Flow--------------------------------------------gallons per person per day: Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-_._______._._.__._ Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter--------------...... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by........ -------------------------•---------------- ...................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 -----•-•-•-•------------------••-•••••-•--•••-----•••••-....-••-•-••----••••••••-•--.......---..._...........---•-=--•----..__............_......------_.....
—0 Description of Soil........................................................................................................................................................................
••••••••••-----•-----------
------------------------------------------------
••----•------------------------------------------------------
•-------------------------------------
--------------
UNature of Repairs or Alterations—Answer when applicable._.lf).314_0---------I_-.....1.6,o_�______ _A.(t._.__.�S'�
ICD........f-•••••-• !.-••-•••-• t�-----------t.......... -------- ........... la.- - -e..........................................
Agreement:
a
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 bee ssu d by e board of health.
Signed --- --------------- ----- - --0J ,,�1`I------------. ---- ....�.....�--f�---C�
Dace
Application Approved By ..............r - ...... .. - ....................................
--'-'------................ Date
Application Disapproved for the following reasons: .. .. .............................................................. ..:..................................
................................ ......................... .............. . ........... -- . ...-........-......-...............-.................. ........................................
Permit No. ........�. f.._.r`F...... Issued ....."''...'
/'�Da/re
c.*.- — tea.—...._.,:._:—.—c--------1——--=.a--— --------————————--. ——,---.a---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of (famplialare
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ......... .`?... ...0........._...................... .._................. -------- ---------.-...--------------- ...... ..................,.....................
at .........................1�t.l...........V
/��has been installedin accordance 4 ce with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ... 'j.. .._�.__ .. f dated .. �:-....'��'' ...."..��..Z
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -,
DATE. -°� , ,/ •"'� __._... Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Miposnl Workii Towitrurtiaan " rmit
Permissionis hereby granted---------------C..., 0------------------------------------------------- -------------------------------_-__-----•-•---
to Construct ( ) or Repair ,,)-,an Individual ewage Disposal System
Street /J ,. ---•- ---� .. .............. r
/ as shown on the application for Disposal Works Construction Permit h�V'oo ...-_.__ .'._. �Date..__.�..._
----------•-•-•- •. = ..... --- ..................................
/ Board of Health /
DATE............. �•--- ................/j-�--
FORM 38808 HOBBS Q WARREN.INC..PUBLISHERS
I
47 ' ^
No..9 2.�.. FEs:...,fS..............
,qaP THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEAL H
44 ......OF.............. S . -----------------.......--•------
Appliratian for Disposal Works Cnomaur#Bnn Vrrutit
App�liccation is hereby made for a P rmit to Construct (A?--) or Repair ( ) an Individual Sewage Disposal
/o SysteU,-U%U4---U --- . -------- ----- �lll�....-- ----- ( ---- ......
o tiop Address or L
........................
f _ caner �� tt Addres /
W ------------------- !....[......--�- f----...........------...............----•- -------•••-------!'�'l-s-----� ����` ..;...---.....
--- ------ -
nstaller Address
Q Type of Building Size Lot....._"��.�_ -----_____Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (L_-�--
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ;1 — Cafeteria ( )
Q' Other fixtures ..................
w Design Flow..............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid,capacity_4$0®__.gallons Length................ Width---------------- Diameter................ Depth------._____----
x Disposal Trench—No. .................... Width.................... Total Length.................... Total Teaching area....................sq. ft.
3 Seepage Pit No......./'............ Diameter...G.Y—P.... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by•---•----------•...-•------•---•---_..••----••----••---•-•-•----•---•_... Date----------------------------------------
Test Pit No. 1_______________minutes per inch Depth of Test Pit.................... Depth to ground water._________:____________.
Li. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------.. _..........
P4 •------•--•----••-----------------•--•----••-----•--••-•-•----•...-•-•----------•--•......---------•.........................................................
0 Description of Soil........................................................................................................................................................................
w
UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
...................
Agreement:
'The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue th o d 1
ZZ
Signed ....................
----••-
Application Approved By._ ._.. i � -_ --------------- ..................
Date
Application Disapproved for the following reasons----------------•----------------------------------------------...---------------------------••----••-----••-----
-----•-------------------------------------•-••-•-------•--•--
Date
PermitNo................................................-....... Issued........................................................
Date
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FEs.............................
�+ r THE COMMONWEALTH OF MASSACHUSETTS �. �
50ARD ®F-7 HEALTH
1 .1,1.,;�`v . OF................
Appliration for Dhipofia1 Works Tonsfrurtion Vamit
Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal
System at•,
Location-Address b or Lot No.
a '
--------------------------•-------.......--------•---..................................... = �------
Owner ' Address
................................... -
y� Installer Address a !
Q Type of Building Size Lot......'_r_---------------Sq. feet
Dwelling—No. of Bedrooms------------�. ........................Expansion Attic ( ) Garbage Grinder ( _)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pi Other fixtures ------------------------------=-------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity!-4`_'__'.___gallons Length................ Width---------------- Diameter................ Depth-------------
---
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------I......_...... Diameter..(__r-_t�__.. Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY.......................................................................... Date--------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----_-_---_ --_--__----
f3:4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-__-_-___-_-_________--.
9 ---•---------------------------------•--------------•---------------------•----------•-----------------•----•-------------------------------------------•--•
0 Description of Soil..........................................>_............................................................................................................................
x
U .----------------------------------------------------------- ----------------------•------------•-----•---------••-------------------------------•---------------------------------------------------
W ..........................................................................................................................................---.............................................................
UNature of Repairs or Alterations—Answer when applicable.._____......................:...:..............................................................
------------------------------•-----...._._._...----•-------...-----•-•----•--------....-----...----•--•---------------------------•----•--•------•-----•--------•--------------------•----•-.......---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the'board of healthf'
Signed............
.......................................----------•--------------------
` Date
Application Approved BY ---------------•---- -----------------------------
Da e
Application Disapproved f t o w yea ons. ___-- _ - .............................................-•---..______�/_?-
.............•-•-•--••-•--••••---------•---•-•--•--•-•---•--•---••--•--•-•-••••••--•-•-..:...................-:.---------------------------------------------------------------------------------....._._
Date
PermitNo......................................................... Issued.................................._.....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................OF ..................
'��leY�#iftr�,t a�rr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY------------------------=
Installer
at............
---- ----- ---------
has been �e X accor he pr vi ions,of_Art �X tate Sanitary Code as described in the
application for Disposal Works Construction Per ' No......... .............................. dated.-____-_________•__-__--____-__-------•-•-_-----
t
THE ISSUANCE OF THIS CERTIFICATE SHAI AO•TV CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI- ACTORY.
DATE--------------------•-------------------,:� L / -----•..... Inspector-------��-4-'
-------------------------------------------------•-•-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.---------------------------------...---------------------------•--...........--....
No......................... FEE........................
-,
otial Warks "Jumitrurtion rprutit
Permissionis hereby granted..................................--------------••••......•-•••••-•-•-------------------------------•••-•-•-••-------••-•-••......••.....•••-
to Construct ( ) or Repair ( ) Fndivi&a%a e_i�posal System ,,k . \
c .
at No..........L.*te""a
-I . ----•--•-•-• --------------------------------------------------..--- i rgc.,
,,,!r ✓ tree
as shown on plfcation fo is or sl9d traction 4;;Ah?No.____•_______________ Dated......................................
......................................................... -----------------------------------------------
B rd of ealt
DATE...............
--------------
�•--- ------------------_��--
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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SEPTIC PUMPING AND INSTALLATION 350 Main St. • W. Yarmouth, MA 02673 • 775-2800
Heating&Plumbing,Fire Sprinklers
SUBSURF E SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property / S11aR£y�
Owner's nameP�R� MAP#
Date of Inspection PAR# 4 i
PART A
CHECKLIST
Check if the following have been do e:
/V01- /VrA/ -�TZ£���qy
►� Pumping information wasyre uested of the o ner, occupant, and Board of
Health. O j hrausi c )-os rO LP
/-OR �SAl_
v None of the system omponents have been pumped for at least two weeks
and- the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into' the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A
V The facility or dwelling was inspected for signs of sewage back-up.
1/1"i
The site was inspected for signs of breakout .
_V_,' All system components, excluding the SAS, have been located on the
site.
' The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees ,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
✓The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods..
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
RECEIVED
AUG 3 1 1995
co
W OF r
ff"DE c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
3 number of bedrooms
O number of current residents
garbage grinder, es or no
laundry connected o stem, yes or no
seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings, if available: Q,u�A!•.ac.,cJ2.t �, .�+� � �-
UA/kAlo w Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
lv'cw
System pumped as part of inspection, yes or no
if yes, volume pumped
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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: PFA-•a,r*e
Sewage odors detected when arriving at the site, yes or Cno
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SEPTIC TANK:
VES SYSTEM INFORMATION continued
( locate on site plan)
depth below grade: �g v
material of construction: concrete metal FRP other(explain)
dimensions: / Qo ° GA
O sludge depth
distance from top of sludge to bottom of outlet tee or baffle
o scum thickness
5: distance from top of scum to top of outlet tee or baffle
_ distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles
depth of liquid level in relation to outlet invert , structural integrity,
evidence of leakage, recommendations for repairs , etc. )
IAI )-r7-
DISTRIBUTION BOX: €S'
( locate on site plan)
0 depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs , etc. )
PUMP CaAMBER: Al
( locate on site plan)
pumps in working order , yes or no
Comments:
(note condition of pump chamber , of pumps and appurtenances ,
recommendations for maintenance or repairs , etc. )
r.
li SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
60I71, ABSORPTION SYSTEM (SAS) :
( locate on site plan, if possible; excavation not required, but may be
I approximated by non-intrusive methods)
j If not determined to be present , explain:
Type
( leaching pits and number
j leaching chambers and number r
leaching galleries and number
leaching trenches , number , length
leaching fields , number , dimensions
overflow cesspool , number
Comm a e n t s:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs , etc. )
I
/V 0
CESSPOOLS ( locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Co�unents:
(note condition of soil , signs of hydraulic failure , level of ponding,
condition of vegetation, recommendations for maintenance or repairs , etc. )
PRIVY: Ala
( 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, recommendations for maintenance or repairs , etc. )
j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
N°� f
�I
�3
3�
/�ou5 t
G
DEPTH TO GROUNDWATER
/V v G-,t7'c e.
T /3, depth to groundwater
method of determination of approximation:
�tsT 1,;/4r i� �iT �N� Gv97rr- ,17
�OT 0ILI Ai111N /a8G4,
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes , no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances . If "not determined" , explain why not
N Backup of sewage into facility?
Al Discharge or ponding of effluent to the surface of the ground or
surface waters?
�✓ Static liquid level in the distribution box above outlet invert?
A Liquid depth in cesspool <6" below invert or available volume< 1/2 da
flow?
/✓ Required pumping 4 times or more in the last year?
number of times pumped
\/ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS , cesspool or privy:
Iy below the high groundwater elevation?
Al within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
A within a Zone I of a public well?
A within 50 feet of a private water supply well?
Al less than 100 feet but greater the 50 feet from a private water suppl
well with no acceptable water quality analysis? If the well has been
analyzed to be acceptable , attach copy of well water analysis for
coliform bacteria, volatile organic compounds , ammonia nitrogen and
nitrate nitrogen.
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector 4M£S
Company Name A & B Canco
Company Address 350 Main Street , West Yarmouth MA 02673
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade , maintenance and repair are
consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems .
Checls-one:
(/ I have not found any information which indicates that the system fail
to adequately protect public health or the environment as defined in
310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303 . Any failure criteria
not evaluated are as stated in the FAILURE CRITERIA section of this
form.
NOTE: A & B Canco has had no control over the use and/or routine
maintenance of the septic system. Circumstances such as a recent pumping
will significantly alter evaluation results . No guarantee or warranty is
hereby given, express or implied, as to , the evaluation.
THE ISSUANCE OF THIS INSPECTION FORM SHALL NOT BE CONSTRUED AS A GUARANTEE
THAT THE SYSTEM WILL FUNCTION SATISFACTORILY
If you have any questions , please call me at 508-775-2800 between 8 : 30 am
and 4: 30 pm, Monday through Friday .
Inspector ' s Signature
Date 5--S- Sr
Original to system owner
Copies to:
Buyer ( if applicable)
Approving authority
Commonwealth of Massachusetts
Executive Office of Enviroiunental Affairs
Dept. of Environmental Protection
One winter Street' D.E.P. Tit Boston Ma. 02108 •Title Grad
Title V Septic inspector
Y.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (S 64!6$'13
Governor I �'
ARGEO PAUL CELLUCCI V
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM e.r
PART A �-Z CJ t,
CERTIFICATION �o N
s�
Q C)9.
Property Address: 15 ShoreyRd.W.Hyannisport Address of Owner: O
Date of Inspection: 618198 (If different)
Name of Inspector: John Graci Lisa Guildford:160 Surrage St. Lunenb r�„Via.01462 CQ
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria defined In Title V
Conditional) Pa5585 code 310 CMR 16.303.My findings are of how the system is
y performing at the time of the Inspection.My inspection does
_ Needs Fur er FAluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity ofthe
Falls septic system and any of Its components useful life.
Inspector's Signature: Date: 6118198
The System Inspector shall/bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A. B. C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
81 SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe,basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
— Colhpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or
the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127197)
One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 Shorey Rd.VV.Hyannisport
Owner: Lisa Guildford:160 Surrage St. Lunenburg Ma.01462
Date of Inspection:618/98
_ Sew.aue backup or.breakout or hiah.static water level observed.in.the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be .
contacted to determine what will be necessary to correct the failure.
Yes No
_ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to en overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04127)87)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 Sharey Rd.W.Hyannisport
Owner: Lisa Guildford:160 Burrage St. Lunenburg Ma.01462
Date of Inspection:619199
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due town overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
colifonn bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
peylsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 15 Shorey Rd.w.Hyannisport
Owner: Lisa Guildford:160 Burrage St Lunenburg Ma.01462
Date of Inspection:618198
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x _ The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_X— — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x — Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)(15.302(3)(b)]
(revlaed 04R7197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 15 Shorey Rd.W.Hyannisport
Owner: Lisa Guildford:160 Burrage St Lunenburg Ma.01462
Date of Inspection:619199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3m g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
n!a
Sump Pump(yes or no): No .
Last date of occupancy: Jan1999
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sahitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nra
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: ria
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source Information:
New system was Installed In 19%
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 Shorey Rd.W.Hyannisport
Owner: Lisa Guildford:160 Burrage St Lunenburg Ma.01462
Date of Inspection:618198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 16"
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age rde . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L6'6^H5'7^w4't0^
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:2'
Distance form bottom of scum to bottom of outlet tee or baffle: ria
How dimensions were determined: Measured
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and ali components are structurally sound.Recommend pumping system every year for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rva
Scum thickness:rya
Distance from top of scum to top of outlet tee or baffle.rda
Distance from bottom of scum to bottom of outlet tee or baffle: rya
Date of last pumpingiil.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
nfa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?own
Diameter: nla_
rvalmments: (conditions of joints,venting,evidence of leakage, etc.)
(reylsed 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 shorey Rd.W.Hyannisport
Owner: Lisa Guildford:160 Burrage St Lunenburg Ma.01462
Date of Inspection:618/9s
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nra
Capacity: rda gallons
Design flow: rda gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
The distrlbutlon Is structuralty sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_ves
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 Sharey Rd.W.Hyannisport
Owner: Lisa Guildford:160 Burrage St Lunenburg Ma.01462
Date of Inspection:619198
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
n1a
Type:
leaching pits,number: JOW gallon leach pit
leaching chambers, number:Na
leaching galleries, number: nfa
leaching trenches, number,length: rda
leaching fields,number, dimensions:n1a
overflow cesspool, number:n1a
Alternate system: rda Name of Technology._nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Leach pit and all components are structurally sound and functioning properly.System never had more than 4'of water In @.PIt was empty at the time of the Inspection.
CESSPOOLS:_
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: nra
Depth of solids layer: rda
Depth of scum layer: n1a
Dimensions of cesspool: nfa
Materials of construction: rya
Indication of groundwater: No
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n1a
PRIVY:_
(locate on site plan)
Materials of construction: Na Dimensions: rva
Depth of solids: n1a
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
n1a
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
15 Shorey Rd.W.Hyannisport
Lisa Guildford:100 Surrage St. Lunenburg Ma.01462
618198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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(revised04)2719T) Pay ! of 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
15 Shorey Rd.W.Hyannlsport
Lisa Guildford:160 Burrage SL Lunenburg Ma.01462
619199
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised0412719T) Page 10 of 10
No..••...........- -�---• .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7.7¢•... ... ---. .OP.... .a!M!.!...,. ...................................................
Appliration -for Uhi uiitt1 Worko Tomitrurtiun Vautit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
�. --------------- ---- �!........... -1� �!"y
-••---
ation-Address or Lot No.
40
W �ner --•-••---••••••----••••-•••-•---•-•••-------Address
,a •••••--• ----� - • -
Inst er Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------••-•---•--•------------------------------------------------•--•-•---.._._..........
W Design Flow............................................gallons per person per day. Total daily flow.........................................----gallons,
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width........_.- .... Diameter---------------- Depth--.._-.----.----
xDisposal 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 ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date----------------------------------------
Test Pit No. I................minutes per inch Depth of "Pest Pit.................... Depth to ground water...---.-.-.--..--.-.-.--
f14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
9 •------------------ ---------------------------•-•-•-•-•-----•---•-•--•---.._..._..•-•••••----•••-••.........................................................
0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W %
x ---------------------- -------------------•-------•-•••--------------------------------------•------I..-•-•• ----•--------- --- --------------
Na;V re of Repairs or Alt rations—Answer when appli 1 _ - _ - ' _.:-._
L.
Ag reement: VV
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by the board of he lthSign .
/
)� Date
Application Approved By------ „ ------- -------- -- ---------------- _-.v__`-- _ .��F...
Date
Application Disapproved for the following reasons:-------•---•-----••-------- ----------•-------•-----____-----•-•----------------_---••----• •--------•-------
-----------------------------•-•---._...._..__..._.._-------•--•-•----------•-•-•---_._...-•--••------------------._...---_.....•.--•-•-------•----•---------.._.---•-------•--------.....-•------------
Date
PermitNo......................................................... Issued........................................................
Date
N
No. -------------- FwE..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... .... . .O F..... ..-........................... . .._......-----......................
Appliration -fur Di.spuottl Workii Tomitrurtiott Vrruift
0 '
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..--•------------•-------------------------•--•--•-•-•------•••---•--•----•-•--- --•-•.....--••-- �!...........................---------•------------•--•-----•-••---------------........--•---••--
{ Location.Address or Lot No.
------...-•-----------•------•..................................•--••--••--••••--••---------•---•. ---•••--------------------•••••-•-•••-•-•--••-•-•----...----•---••-------•---••-----------....----
Owner Address
F-1 Installer Address
QType of Building Size Lot............_.............__Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _________________________•- No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter______._.-_____ Depth--.---._-__-----
x Disposal Trench—No- ____________________ Width-------------------- Total Length........_........... Total leaching area------------.-------sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) •
aPercolation'Test Results Performed by------------------------------------------------------------------------- Date--------_---------------- ---•-------
Test Pit No. 1----------------minutes per inch Depth of Pest Pit - Depth to ground water-..-_____-___-_--__.__..
f� Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
----------------------------------------------------------------------------------------------------------•----------------------------------------•----------------•---------------•--------------------••-•---••-----•-•---•----------------------------•-_.._.
ODescription of Soil-------------------------------------------------------------------------------------------------------------------------- --•---- .................... -----------------
.............................................................................................................................................•--------------
--------------------------W
U Nature of Repairs or Alterations—Answer when applicable________________________ _____-I-______-_--_-_:._--.-•-._-__-__-__.-_--__--...___--_:_______...
r
Agreement: I
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
...r,.__ 3
Signed_._
�� -
Date
Application Approved By--• F ! C. -• C'"�..!a!�/} r�'' �� -
` Date
Application Disapproved for the following reasons:................................................................................................................
--••-••-•-•---------------•--••...•-----••••---..._--------
Date
PermitNo._..................................................... Issued..................... --------------•----------------••
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I
......`.......................-•...........OF.....................................................................................
(Irrtifiratr of 01.umpliunrr
THIS IS TO-CERTIFY, Tha,the Individual Sewage Disposal System constructed ( ) or Repaired11-11
( )
e p r Installer
r j
-- '/+ --- `
------.-.--•-------------------------------------•-•-------•
has been installed in accordance with the provisions of A}}'' -I'e XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------ �—..__.___.__. dated._ _ ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNC ION SATISFACTORY.
DATE........... .• " � Inspector•_ •. ---------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF/............ .......................................... --.-- �.
No......................... FEE....-•--...............
Dinpoottl Morkii Tlotmtrurtiott Vrrmit
Permission is hereby granted `* 11
-------•--• ...... ..-•----•••`------•-----•...................................•••••-•----......•-•-•---------
to Construct ( ) or Repair ( ') an-Individual Sewage Disposal System
atNo. =-"-----------------------••--......------...........-- ------------------ �-------f-------------------------------------------------
/ Street /,, _ ^7 /
as shown on the application for Disposal Works Construction Perm o-------- __ _ D,axed-----___...................................
Board of Health
DATE_�`..�:... ..---G-'------�---------------------•----------------------•
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
I qO/079 .
LOCQTIQN ' ` SEWo,C,E PERMIT MO.
_ VILLAGE
INJ5T L L E R 5 dUl,NlE AD ESS
BUILDER 5 1./lE ADDRESS
DIATE PERMIT 155UED '
D ATE -COMPLI &&ICE ISSUED : ��'6
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