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HomeMy WebLinkAbout0184 STRAIGHTWAY - Health 184 Straightway Hyannis P A = 268 102 ti 1 .f o e e e � TOWN OF BARNSTABLE I.C.-CA11ON 6 SEWAGE # _y VILLAGE Ike(CAkl I S ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ;+ (size) 4 t NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet Furnished by �'��► j LEACH PIT 'o o_Bo,: LOCATIONS A B z 1 4FL 16.5ft SEPTIC TANK® 2 ''12 FL 20 f t ' 3 20.5 FL 25.5 Ft a 4 33.5 ft 15.5 ft EXISTING DWELLING # 184 W Z J ' K W r al , STRAIGHTWAY NOT TO SCALE TOWN OF BARNSTABLE ;. SEWAGE #/X/" S /�/fI Gy��L:n ATION /� 'VILLAGE /T / ASSESSOR'S MAP & LOT N.SP Fc/o,P S n �d T —W&NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS ,tom BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by R� V � � �„ n M \ a O /11pJ t y Commonwealth of Massachusetts r W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is August 30, 2008 Hyannis MA 02601 Au required for H Y g every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information I ' forms on the computer, use 1. Inspector: only the tab Ivey to move your David D. Coughanowr cursor-do not use the return Name of Inspector key. Eco-Tech Environmental Company Name 43 Triangle Circle Alf Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and thk"Nhe : information reported below is true, accurate and complete as of the time of the inspection. -TM Inspection was performed based on my training and experience in the proper function and ma''itenance 6f onrs)te t sewage disposal systems. I am a DEP approved system inspector pursuant tom' ction tt,340coof Title 5(310 CMR 15.000). The system: <a ® Passes ❑ Conditionally Passes ❑ Fails' , ❑ Needs Further Evaluation by the Local Approving Authority w rTt �S August 30, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page i'of 15 r Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'M 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is Hyannis MA 02601 August 30, 2008 required for y g every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,E,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determines (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backuo or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is August 30, 2008 Hyannis MA 02601 Au required for H Y g every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-3019.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is g required for y H annis MA 02601 August 30, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to cllogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is Hyannis MA 02601 August 30, 2008 required for Y g , every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 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 should contact the appropriate regional office of the Department. t5-3019.doc•08106 Title 5 Of dal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <c�M 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is g required for y H annis MA 02601 Au ust 30, 2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El M Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Leach pit also inspected ® ❑ 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_he condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-3019.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy:tem-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is H annis MA 02601 August 30, 2008 required for y g every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 253 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is Hyannis MA 02601 August 30, 2008 required for y g every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yas 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, date installed (if known) and source of information: Age: 24 years. Certificate of Compliance issued 9114189 (Board of Health permit#84-516) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is August 30, 2008 A Hyannis MA 02601 u required for H y - g every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer behind finished wall and not accessible for inspection. No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: At least 1000 gallon Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design plan t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts ti v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is Hyannis MA 02601 August 30, 2005 required for y g every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Do not dry ve or park vehicles over septic system. Grease Trap (locate on site plan) Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top cf outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is August 30, 2008 Hyannis MA 02601 Au required for H Y g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At outlet invert I Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Do not drive or park vehicles over septic system. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-3019.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is Hyannis MA 02601 August 30, 2008 i required for _Y g every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. Standing effluent was observed.at a depth of 2 feet below the top of the leach pit. Pit is in marginal condition and new owners are advsed to reduce flow. Do not drive or park vehicles over septic system. t5-3019.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is August 30, 2008 Hyannis MA 02601 Au required for y 9 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): t5-3019.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is Hyannis MA 02601 August 30, 2008 required for Y g every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent refereice landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LEACH • PIT 30 o_eox LOCATIONS z A B SEPTIC a 1 4 Ft 16.5 f t TANK o 2 12 FL 20 f E 3 20.5 f f- 25.5 Ft e A 4 33.5fE 15.5f't EXISTING DWELLING # 164 W Z J 0_ W H 3 STRAIGHTWAY NOT TO SCALE t5-3019.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 184 Straight Way Property Address Ronildo Coelho Owner Owner's Name information is ust 30, 2008 Hyannis MA 02601 Au required for H Y g every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 13+feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9113184 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 5.5 feet above the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-3019.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Date: 6 / lO(0 TOWN OF BARNSTABLE TOXIC AND ZARDOUS ATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ���rTfS �&kb E 6PAN1Te. A SQWC_5, BUSINESS LOCATION: !8S 571eAl TWA\/ IN MAILING ADDRESS: 18q, `STVA i 6 TWAy TOTAL AMOUNT: TELEPHONE NUMBER: SO 7 44L 42,0q. CONTACT PERSON: 01 Amy Loci I —� EMERGENCY CONTACT TELEPHONE NUMBER: (5018) 8M- ,66' MSDS ON SITE? TYPE OF BUSINESS: 6 INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous_waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive I NEW USED Cesspool cleaners Automatic transmission fluid Disinfectant s is Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) ti NEW USED \Any other products with "poison" labels Paint&varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers �A..Ininj (including bleach) �� �u 5 Spot removers & cleaning fluids CeA-'t/,g (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS >Vl qu the sewers, materials of )f the sewage treatment process, , ant, degree of treatability of wastes .her pertinent factors. The >r having a temperature higher than -enheit or sixty-five (65) degrees containing fats, wax, grease, or xcess of one hundred (100) mg/1 or dify or become viscous at and one hundred fifty (150) degrees ve (65) degrees Centigrade. as not been properly shredded. The rbage grinder equipped with a motor .76 hp metric) or greater shall be f the Superintendent. es containing strong acid iron ing solutions whether neutralized or es containing iron, chromium, ble or toxic substances; or wastes rement, to such degree that any such ewage at the sewage treatment works e Superintendent for such materials. es containing phenDls or other taste h concentrations exceeding limits t Town of Barnstable TFIE� Regulatory Services Thomas F.Geiler,Director J r • Building Division '�' lAR1Y5fABLE, +�` v ass• * Tom Perry,Building Commissioner �A�ED MAt p�0 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date: CGI")23"G. Name: N 1 )D0 CoE) �o Phone#: C���� �� - 20 LI. Address: 6TPA r. TViA' Village: P dl , Name of Business: ABB 1s '"1 E G� Te S!! SQi2.V i US. Type of Business: &N EVAI -Cey 1 Qs Map/L,ot: �v Of 00;� INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises•which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pickup truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigne , a`v�e eati� agree with th above restrictions for my home occupation I am registering. l Applicant: l`l � Date: Homeoe.doc Rev.5130103 TO ALL NEW BUSINESS OWNERS 11 / DATE: Fill in please: ►. 5400%JDO &J�01 APPLICANT'S YOUR NAME: BUSINESS , YOUR B�IIOME ADDRESS: 18 (reT d A TELEPHONE Telephone Number Home NAME OF NEW BUSINESS KA56ITS MAPMbG. QANiTE & SC-Avi CeS TYPE OF BUSINESS Gc�tcQA C • Q�i'G2S ►� IS THIS A HOME OCCUPATION? YES N ou$e5 G CA d:��N Have you been given approval rom the bu!'Iding ivision? YES_NO F ADDRESS OF BUSINESS 4$ S`�A�6 hTkWA MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be incompliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained the required signatures, listed below, you may apply for a business certificate at the Town Clerk's Office (Ist floor-Town Hall) or if you get the business certificate first you MUST go to the following office to make sure you have all the required permits and licenses.. GO TO 200 Main St.—(corner of Yarmouth Rd. & Main Street) and you will find the following offices: 1. BUILDI MMISSIONER'S OFFICE This indiv ua h been,iyrfpr a of any permit requireponts that pertain to this type of business. L, Au thorized 04nature*' COMMENTS. - to -EYOW 6CCXL �- 2. BOARD OF HEALTH �u, iZ a Qq This individual has b inform e f t ermit requirements that pertain to this type of business. thorized gnature" COMMENTS: v 3. CONSUMER FF -RS (LICENS G AUTHORITY) This individual a informed o t ice sing requirements that pertain to this type of business. Authorized Signa re" COMMENTS: -- Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. -it does not give you permission to operate -you must get that through completion of the processes from the various departments involved. "SIGNIFIES APPROVAL FOR A BUSINESS CERTIFICATE ONLY. TOWN OF BARNSTABLE LOCATION B`Y 3pppi c,Kr I..'d y SEWAGE # VILLAGE /� ASSESSOR'S MAP & LOT I INSTALLER'S NAME Cz PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS PRIVATE WELL OR P LIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: g DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No e - w Vk n d; 5 2w2-3ao ',-• No. Fee Jv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Digooar 6potem ttCongtruction Permit Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System P9,Kdividual Components a Location Address or Lot No. `g� 5 Owner's Name,Address and Tel.No. £�� j 7 t '� Assessor's p/P e Installer's Name,Address,and Tel.No. ���. 7'� �ko® Designer's Name,Address and Tel.No. / i�//0'0 C�y"C 0 3 sif Type of Building: Dwelling No.of Bedrooms Lot Size • ,�sk-fr-- Garbage Grinder( ) Other Type of Building NA S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 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 issu y this Board of Healt . Signed Date �'3 �'" �2 Application Approved by Date ts2 Application Disapproved for the following reasons Permit No. r mz- 3 Date Issued -,tb 02 No. L - Fee `✓ Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for Ztqooal stem Conotructton Permit Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System C41Individual Components -Location Address or Lot No. �� S 7� Owner's Name,Address and Tel.No. d 7 y d_ 0 .2/6 �1G�T t�,.ly ��s t� �Ftitii.S Assessor's Map/Parcel, f 6f 7k n 1' .-7- Installer's Name,Address,and Tel.No. sQ�. 7 S .290,o Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size �sq-ft-- Garbage Grinder( ) t Other Type of Building i1Q No.of Persons Showers( ) Cafeteria( ) Other Fixtures 'µ`x. "`Design Flow gallons per day. Calculated daily flow gallons.; Plan Date Number of sheets Revision Date ..Title Size of Septic Tank Type of S.A.S. y Description of Soil Nature of Repairs or Alterations(Answer when applicable) ' Date last inspected: i Agreement: The undersigned agrees to ensure the constructionand maintenance of the afore described on-site sewage disposi6system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y this Board of Heal Signed Date Application Approved by Date Application Disapproved for the following reasons 1 Permit No. Date Issued UZ i -------------------- ----------------- THE COMMONWEALTH OF MASSACHUSETTS j BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( 4— 'Upgraded( ) Abandoned( )by A / at /B k TIP/9/`yr A,/l Y has been constructed in ccordance with the provisions of Title 5 and or Disposal System Construction Permit No. 7 0)1- �Gated R'/3(J0 ? . Installer Designer The issuance of this e• shall not be construed as a guarantee that the s 'ste ill function a�9s designe,�l. Date /C Inspector G i r , —-------------------------------------- No. Fee ` '.� r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS loi5po5at 6potem Conotruction Permit Permission is hereby granted to Construct( )Repair( 4- pgrade( )Abandon System located at / $1 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this/;ermit. Date: I` I c�2 Approved by,\ .. Y �- TOWN OF BARNSTABLE LOCATION_._ 8`y �1E1 r�f(T tv,��/' SEWAGE# SM VILLAGE Ilk' ASSESSOR'S MAP & LOT I i INSTALLER'S NAME & PHONE NO. A & B C Q0 775-6264 i SEPTIC TANK CAPACITY /E' f WLd c £ LEACHING FACILITY:(type) (size) NO.OF BEDROOMS �' PRIVATE WELL OR P LIC WATER BUILDER OR OWNER .415 Foe DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No _. life I IDZck a 35.E o Z- COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE® MAIN STREET W S E P 2 5 2002 WEST YARMOUTH,MA -IL;O 508-775-2800 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ! �p MAP 268 PAR 102 Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner's Name: KAISER,DENNIS Owner's Address: 50 ELLERS DRIVE CHATHAM,NJ 07928 Date of Inspection SEPTEMBER 4,2002 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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 to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: ,; 2 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 tot he 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 1 i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 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 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 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 C. Further Evaluation is Required by the Board of Health: N/A _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR I S.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: N/A To be considered a large system the system must service a facility with a design flow 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—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the Condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X 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 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2001 7,400 cu.ft./2002 6,700 cu.ft. Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): 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): GENERAL INFORMATION Pumping Records Source of information: 2001 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system 1 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: AROUND 1984. NEW DISTRIBUTION BOX AUGUST 2002. Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 BUILDING SEWER(locate on site plan): X Depth below grade: 10" Materials of construction: Cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X t Depth below grade: 18" Material of construction: X 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) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or baffle: 27" Scum thickness: P, Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.TANK AND COVERS 18"BELOW GRADE.ONE INLET TEE,OUTLET BAFFLE.NO SIGN OF OVERLOADING SEEN IN TANK. i GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate 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.,): DISTRIBUTION BOX IS NEW-AUGUST 2002.BOX IS 16"XI6",20"BELOW GRADE.ONE LINE IN,ONE LINE OUT.OLD BOX SHOWS NO SIGN OF OVERLOADING OR SOLID CARRY OVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) I If SAS not located explain why: Type X leaching pits,number: 1 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.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER IS 32"BELOW GRADE.T WATER IN PIT.NO HIGHER STAIN LINE.NO SIGN OF OVERLOADING OR SOLID CARRY OVER,WALLS CLEAN. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property,Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a 3� �l �-FCXF (� f)k �J Title 5 Inspection Form 6/15/2000 10 Page 1 I of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 184 STRAIGHT WAY HYANNIS,MA 02601 Owner: KAISER,DENNIS Date of Inspection: SEPTEMBER 4,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 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: Observation site(abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation X Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND DUG TEST HOLE, 12'NO WATER. TEST HOLE Y BELOW BOTTOM OF PIT. i 9 1d p O d /A/C' Title 5 Inspection Form 6/15/2000 11 r N 1 No....9 q- .Jr../„6 Fims.... .......�...... THE COMMONWEALTH F Ts BOARD OF HEALTH av C / cs.w.'J...............OF........... ........................ Appliration for Ilhgpos ai Worko Tonstrnrtiun Frrmit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: 4_.. .... .................... Location-Address or Lot No. i ....... .. ------------------------------------------ ........................... ... ......_... ® Address a ...............................................p . 41 Installer Address Q Type of Building Size Lot.... r_✓.O O Sq feet t Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ............................ . W Design Flow.................t 5----_-------_-__gallons per person per day. Total daily flow---------- ....................gallons. WSeptic Tank—Liquid capacity/4?4lt2gallons Length.....a..... Width-------- Diameter________________ Depth_---4...... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------- ............. Diameter.. Depth below inlet.....-.............. Total leaching area.501m . 6 Pb Z Other Distribution box (V.� Dosing tank ( ) A Percolation Test Results Performed by.... _ ___. ...... Date_..". Test Pit No. 1----G..Z-__minutes per inch Depth of Test Pit---- '6_".__ Depth to ground water_.A� T...9PY fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground waterCCV.AJ" 4E1> ----------------------------- •................... •---------------------------------------------- -... ---... •-•-----------------------•------------------------ ODescription of Soil.................... 4-_. _._........11 ........-•---••-----------------------------------------------•------•-----------------------........-•------- x c, x -----•----------------------•------•------------•----------------------------...-••--•-----•----•-------------------------......--•------••----------------------------••-•----•--•-•.................. U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ii/sssu_�ed y,t e boarrVhealtSigned �'lcS�_ •..................Date----------.... Application Approved BY---••------•--=��� _-'^ram . .. ... .............• ............ Application Disapproved for the following reasons- --------------•----•---------------•------------------------------------...................................... .......................................-----•-••...----...------•-------...------------•------------•-•----------•---------•--------------------------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date *xop g LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME A ADDRESS 4 D U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED q Cn a° �, _ - i �' w w � � o � , ® 04 �� � - - A � ,' No.. ��_= .�.. F>s.... .......t + THE COMMONWEALTH OF MASSACHUSETTS I~� BOARD OF HEALTH . ...:............OF...........Z tJ."C...c�-?. Lam{`--------.-------------.-- .� firation for Bitipos al Workii Tonstruriion rrrntit Application is hereby made for a Permit to Construct ()<) or Repair ( ) an Individual Sewage Disposal System at: ....z........: �.r ?e.f.. :- s•- l-�..e........................ •. ................../ --===.... �' .....- - Location-Address or Lot No. a Address ' s -- ------------ ...................................................... Q Installer ............................................T e of Building Address YP g Size Lot.._!?..-_3_U Q.Sq. feett Dwelling—No. of Bedrooms------------ ............................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type e of Building * ....._.. No. of persons............................ Showers � YP g -------------•-•---- P ( ) — Cafeteria ( ) d Other fixtures W Design Flow............... j.....................gallons per person per day. Total daily flow.........?_. -o.___.................gallons. WSeptic Tank—Liquid capacity/n�cxAgallons Length_.....a_'__. Width...... `_ Diameter................ Depth-..., !..... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......!-------------- Diameter../._Q.t_C!... Depth below inlet..... :........_.. Total leaching area 31v_ .-sq, t.� p D Z Other Distribution box ( Dosing tank ( ) a Percolation Test Results Performed by._./_j t-j... ----- Test Pit No. I.....4-'...minutes per inch Depth of Test Pit.. '!... Depth to ground water..A._t/i 7.....t5A.?— 04 Test Pit No. 2................minutes per inch Depth 'of Test Pit.................... Depth to ground 9 ---•---•••---•----------------•---...........••----------•••----••--•......•......_......-•-••---•-•......................................................... 0 Description of Soil.................. --------• � ......----•---•-------•--------------------------------------•------•---. VW ------------------------------------------------------------------------------•-------------------•-----------------------------...--------------------•-----------------------•-•••---•...•-----•-- Nature of Repairs or Alterations—Answer when applicable................................................................................................ -------•-------------------•------------•-•-------------------------------------------------....------•-------------------------------------•--------•------------------------------------........-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 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 he d oZT. .t G Signed-------•....)--rgz.-- •. ----•-- .........)...-- F_ ��U Date Application Approved By................------•••--=----•-•-• , ......•... .Date.............. Application Disapproved for the following reasons__________________________________________________ .............................................................................-••-•-••---...---•--.......---...-••-••-••-•----•----•-----•-•--•-----------•-------.................................... Date PermitNo........................................................ Issued--•--•--------------................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... %Trriifiratr of flnntpfiFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................... , ... ... ....................................................................................................................... ns ler --------------------•---------------.......---•-••--•-•--••---- has been installed in accordance with the provisions of TI PIE /of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... ----- dated-.dated-......----------------------------- .......... THE-ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. G�.- n DATE L ------•------.....r -----•---- Inspector........--'- k_.4p.................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............................OF...................................................................................... 57A No........ ! FEE........ ................ Disposal Workii Tnnstrnr#ion Trani# � Permission is hereby granted------------•••--•• C,e�.. ./! - .................................................................................... to Construct ( ) or•.Re air ( an Individu ew a pisp6sal System { at No. -------- ------------------------------------------------------------- -------------------- Street as shown on the application for Disposal Works Construction Pertja4 No..................... Dated.......................................... �•- w Board of Health DATE................................. FORM I258 A. M. SULKIN, INC., BOSTON i c ' 1 L0 C T ION SEWAGE PERMIT NO. C VILLAGE 1a�- INSTA LLERIS NAME i ADDRESS t U I L D E R OR OWNER DATE PERMIT ISSUED ® ATE COMPLIANCE ISSUED L G - a 4 w 4 N ............. FEE ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' Appliration for Elhipogal Works Touarurtion Vautit Application is hereby made for a Permit to Construct (k) or Repair an Individual Sewage Disposal System at: ...........Anle- IJ4 Y ....4LE�lr..................................................... ................................ ................97.................................... _j,agglion-Address or Lot No. ......... -------n---------------------------------------------- ----------------------------------------------Ad—d-r—e-s-s-------------------------------------------- W - ..k. .................................. . .................................... ......--'-- Installer Address Type of Building Size Lot-01...PP-0....Sq. feet lk U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder h4 P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures -------------------------I..................­------------------------------------------------*---------------------------------*---------------------- Design Flow........... $75........gallons per person per day. Total daily flow..._.......Z Z-'�::'......................................gallons. 04 Septic Tank—Liquid capacity/900gallons Length-----e...... Width...... ---- Diameter________________ Depth...-4. Disposal Trench—No......................Width_....._.. --------- Total Length....._......._ Total leaching area............ sq ft. Seepage Pit No........I----------- Diameter.../0..#5..'_ Depth below inlet.....4.......... Total leaching area.-V...!-4 4--it-6 PZ> Z Other Distribution box Dosing tank Percolation Test Results Performed by....4�q.!5�.... OJC.��4�9..... ......... �-4 Test Pit No. ....minutesperinch Depth of Test Pit....tf-4.1.1.. Depth to ground water-4I"....6 rzq Test Pit No. 2................minutes per inch Depth of Test Pit____............._.. Depth to ground water. q !� 94 ............................................................................................................................................................. 0 Description of Soil---------------4 c. .........PLA_�...................................................................................................................... U ......................................................................................................................................................................................................... W ..........................I............................................................................................................................................................................. U Nature of Repairs or Alterations—Answer when applicable.............................................................................................. ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE TL LE 5 of the State Sanitary Code.— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be iss d b e boa of h Ith 2 Signed.—I 0_4--1- ................. ................................ ...... .... WA Application Approved By .................................... ...................... ......��/ Y. . .............. Date Application Disapproved for the f ollowin9 reasons:................................................................................................................ ......................................................................................................................................................................................a---------------- Date PermitNo........................................................ Issued....................................................... Date tN } No. ....? .1.. FEs..... .il................. r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .---U G--- -...... .........:OF........ �.!`�.�-'./J,,STH-� AVVliraation for Disposal Works Tonstrnrtinn Vrrutit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal System at: .s 724 I G H T' tJ j Y 7' 87=....----•---•--•-_..._._.....•-•• - -•.................••-••--••----...... ............................................... N ......................... Location-Address orL .tm® 1 ..l(,,�_-.x........... �.. .............................................Add ----.......................................... .Owner W p,• �, •. ress a ................:. ---------------------- ..--------Add--•---ress•------ •------- _------------------------------ • Q Type}of Building Size LotI4__O s2_�....Sq. feet f Dwelling—No. of Bedrooms.............._'- ..........................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building _____________ No. of ersons............................ Showers a g ----•-•-•----•,- --...........--P--___._ . ( ) — Cafeteria ( ) Otherfixtures •-- • •-------• ••• ••.-- -•- •---•••-••--•-• .....•-•••............... Design Flow.......... __._-3� ........gallons per person per day. Total daily flow_..-__-.__.��__ 7__________________gallons. ::4 Septic Tank—Liquid capacity/Qj99gallons Length____'._....... Width_____'.`::'_'Diameter________________ Depth____'._.. Disposal Trench—No_____________________ Width.................... Total Length.....:_____:__...... Total leaching area._.____-....__._____sgAt. Seepage Pit No.......,-___________ Diameter._/0.:__ Depth below inlet.....��2:�__.__.. Total leaching area_-'5r_ prj Z Other Distribution box O Dosing tank ( ), Percolation Test Results Performed by--- ___ ._-_64e, _:_Lg.e....../%z ..... Date._, =__z3_:'_0_4_____.... a a Test Pit No. 1__ _2.___minutes per inch Depth of Test Pit.... : .''_ Depth to ground water.k!,j__f_.___4Z fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground waterC .................................................. •-------•--•--•--_--•- D Description of Soil--------------- ....__._.P_!,-A-``�x •••---•-•------•-••-----••••-•-•----•••---•---•-••---•----•••-•••••-•-•--•------..._.. V ........................................................................................................................................................................................................ W U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------_____-____. -------------------------------------------------------------•--------------------•-._......-•-------------------------------------------------------------- ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z- 5 of the State Sanitary Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been js.si 4ed th and o ealth. dSigned...... � - - - - ----•- -- ---_- ••- ................................ Date Application Approved By............ -- ---------------------------- ------- ---------------- ....... ---------- Date Application Disapproved for the following reasons:............................................................................................................... .................................................................................------•-•-•••••••--------•---•---•--•- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Cnrrtifiraat.>' of Toutpliaam THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer at....................... ✓= -•- ,� ------------------------------------------••••- ' ` ---------- has been installed in accordance wit i the provlsions af'TITLF 'S of TheState Sanitary Code as described in the application for Disposal Works Construction Permit No....... _!_ _____ T dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE........::-•----.._...--•---•.._..----•--•-••__--.�r•-` :.��....:__ Insp tor..._..- n:-------•-••••-•••---•---....................................... THE COMMONWEALTH OF 'MASSACHUSETTS c BOARD OF HEALTH No........................... FEE............ * Disposal Works Tunotra lion Vprrutit Permission is hereby granted- a --�Z.,............-------------------------------------•-----------....-----.................---.... to Construct ( ) Lqr'Repair ( ) an Individual Sewage Disposal Syst_ yw, r` Street as shown on the application for Disposal Works Construction 'Permit No............11,......... Dated.......................................... DATE_ Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON � ~ (i - TG71 p Fa F vt.1►1 P A"(' rj - SS.Of9 54 - _ SO A IL 4 4 - ti O TE E X 7-C,-/D F9 L L- C T O A-J — l/ E 7- S C i9 L E- / = /O' ,VHOL E co vc-Rs TO �iJ/TH/ti — - -- �—a — P�oPosed ground Pr-of'i le /2" OF FlNIsHED G �?AGE . S C HE D. 40 P. v C. 0,2 F L O w --- ------ -T EOuAgL 7-o SEOTic Cr-,,Inirnurn Y" fir- -yoo->-) 2 of �B ' �2^ wa5hsd SJ�one NIJ �—3 TfiNK 1 a C e o - ° ,. D/57- BOX d,a _ a �o to Svrr,p /000 Gf�L :..SEPT; C 7-,-9A 'AC Zof —_. -------. .- -- _ o ° -- DE- 3 G /L/ -- - - _ TEST HOB E- LOG S3. _ s Z- _ B E'D,2 O O M /•-1 O US E- D A 7 C .-1__.�_ _-- T E-5 T B 7- GV TIV E S S : fZ 41 FVrOV V eL,&V,4-5TAe>LE ._._Lw _ ._14t-&A Trl Sw TES t �v L O W 2 ATE ?ZO_ _ GALS./Di9Y DATUM W M SEPT/G TFF�Nk z2o x /. S = 330 TEST HOLE / TE ST HOLE• #Z � ' L0'T 1Z4FYJ5�o USE : I000 GAL. TAAJ,iG � 87 pwELL1uG o Q� I p/o�00 •1- 525`or • zo. '�' L E f9 C H P/ T EFF. DEoTH Cr o 6 05501 L 4 __.. T ri B O"T-TOM (i 5 F 1 O ) r $�w.Co . �- 707 L 40. 51.P - I -- USE. f 4e- Ei9cr-I �i T V 52 s utT a E ' cL, z r.7p.0o 4p. A . 0 i4L" / GE,2T/F Y Tf-/AT T'HE BU/L D/AJG / -�-� _ G / - / G E / ^ ,� / PitOPOSED on./ THE G�2OUND F9S / G_ L/\/ (_ �J /\/ Sr-/ Ow,v OAJ 7-H/ 5 GLFgnJ DOES Fo2 . LOT 87 - 5T2AI6i,-A-' W4,y - SI�Qti► ST/�BLE GON�=0,2M T-O THE BU/LD/A/G ,5E•T- REF£R tcvq"t' •PI,,Q1J 1132-8o 5+•{ 1 B/QCK A2EQv/)eEME�lTS OF THE . N 6 Z. O 4- J Aj D A T E y�U IJ E I' EVERETT H. yc 1 HIRETT T / � HtNC30 Io �NCKLEy N V 13230 -.f 3/�/ o p CIVIL O "/ Q 1767 O /STER4 S � f�L E / =30 fss�ONAI ENG�'N AND SURV�'y � O o o e x IS-1-1 n q e /e vat!o r-1 7- f�c,� / }- ,c3 i 2 /"I O v 7- f9 S S. [0. 00 _ pf-oposed a /e va-t-ion .r2EG7U/ QE-ME ti/TS con favrs 9 5 de io f3F�PQC) vE D — -o — a— /n�oPoSed con f-oU�-s ree i - orIo BOARD of HEALTH ---_ M 4 -- -roe 54 a �Q Foy ►3t�/�T�cR.4 ----- 7 - ( -- S2 — _ P14 _ -- ._ �4 __ _ .__ _- - -- - �x.cr t - t.. iwC © - - -- 44 _ 4 A,1 O TE ExTC-KJD f4L L A PPL iGA 451 � e x ;51f-in .-c.a rr c� �-o '' ''' � f MAaJHQL e C O V F-RS 7-0 Lnl/Thllti r 9 � � f� !� ` T_ .• ; r O, !� �� o ---- o — o---c SCi-4ED 40 P. VC. CAR E©Uf9L 7-0 SE©T/C �rr�,n,rnvrn X faE r -Co 0+ ) "---` D/5T. BOX .70 0 N D , C p M H O[J S E TC B Y , r +i 10- 9 T ! Z.5 PE E'C. ,2 N TE cv r-r`iv E S.5 . �►� �g1�2stST, .�. ._--usL.a� ��A� N __ ._._ r��.v�/Av C N { , Al-ap f�ivi -, _ ;" L O LA AZ? r9T GFa1 5./%D19Y S P T/C 7-r9 n./Ae- ?, K 5 _ TEST H O L E 1 1 u sE- - __. � L. -r qA✓,� MXI 17 12� o, { G E/9 �i ` t 3 od o' k E FF• D i A2.4 - t3Spt E / j r r - - }+` 5i.+P �•► _ _+ DE Ln/.�)L L _ +9'7.9 !S ( J ! � r to f) '56NC14 M?421k N I'7 LEACr-/ Fri T 1 49 18 vjl:aT,�2 IF- L J?,A E.c / F'�2oPo5E D c7.�r THE GE'�CJND i95 �� �� �' A-/ sHowA✓ ory rH� s P� rvn� rows . [ r:/_'a1G40- 12N 6 GONF0�2M Ta TNF V5- Sz 1-4040 r-062-T p.,nr1 3 2 8 � 5►a• 1 8 A C SIC' E Q C.0 r AF E/`-7 E A-1 TS 4 r y F FOA2. VE- SC N,:' t,3 ,-40 ,� Swr`1 Df�TE � 9 4 / HINCKLEY 13230 �U ii1 CKlfY Clvll O w 'A 1787 O �0- C'/STEQ� 0 00 - exis-t-� nq e /e� vaf�on BLDG- S��-Bf�c,� '' C O o Pr-oPose d e /� VG-t /On �'E QU/,eE M�ti/T5 — - -- — -- � i5f in COn fOUr� ->C!" Or� X `� S , d ,o �9 F'P2 o vE D 1'eQf"'_ �o BO�F2D Ors HEF-?C_ 7'H