HomeMy WebLinkAbout0033 DANIELE STREET - Health 33 Danielle Street
Cotuit --- - -- --
A= 027-077
TOWN OF BARNSTABLE
LOCATION " SEWAGE #
VILLAGE CONEESSO 'S MAP & LOT 07
S,P�CTot2'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 60c) , 7C-JYLA N.�-�I,
LEACHING FACILITY: (type) C>J (size) /000
NO.OF BEDROOMS
BUILDER OR R
PERMITDATE: 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 facility) Feet
Furnished by
�1
achusetts
Commonwealth of Mass
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
CGM 33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
Iforms on the 1
computer, use 1. Inspector: I
only the tab key p
to move your Matthew Gilfoy
cursor-do not Name of Inspector
use the return
key. B&B Excavation
Company Name
r� 14 Teaberry Lane
Company Address
Sandwich Ma. 02644
City/Town State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1-16-15
z
tor's Signa Date
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.
t5ins•3/13 Title 5 Official Ins ctio rm:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments
33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
❑ 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.
Check the box for"yes", "no" or"not determined" (Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Danielle Street
M
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
qM 33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
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.
❑ 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 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 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 '/2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is
required for Cotuit Ma. 02635 1-16-15
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
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. [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 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 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. Cityrrown. 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?
❑ ® 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?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the 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)]
D. System Information
Residential Flow Conditions?
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d see below
9 ( Y 9 (gP ))�
Detail:
2014-9,000gallons 2013-10,000 allons
Sump pump? ❑ Yes ® No
Last date of occupancy: September 2014
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): NA
Gallons per day()pd)
Basis of design flow(seats/persons/sq.ft., etc.): NA
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: NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Danielle Street
M
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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 (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
.maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is
required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
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.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
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: 1000 gal.
Sludge depth:
2"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Danielle Street
�M
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
34"
Scum thickness 211
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
up.Liquid level equal with outlet invert.
Grease Trap(locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: NA
Scum thickness NA
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
Date of last pumping: NA
Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
NA
Capacity: NA
gallons
Design Flow: NA
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Danielle Street
M
Property Address
Paula Fullerton
Owner Owner's Name
information is
required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
At time of inspection d-box appears to be in working order with no signs of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
ECEBEEW
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Danielle Street
M
Property Address
Paula Fullerton
Owner Owner's Name
information is required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
®
leachingr:
1 (6'X6')pits number:
❑ 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.):
At time of inspection leaching appears to be in working order with no sign of hydraulic failure.Water
level 4' below invert at time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert NA
Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA
Materials of construction NA
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is
required for Cotuit Ma. 02635 1-16-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: NA
Dimensions NA
Depth of solids NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth:' f.Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Danielle:Street:
Property Address
Paula Fullerton
Owner Owner's Name
information is
required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide':a view of the sewage disposal system, including ties to
at least two permanent reference land
marks dmarks or.benchmarks: Locate all wells.within 100 feet. Locate
where public water supply enters the building:Check one of the boxes below!
P PP Y . g:
hand-sketch in the.area below
0 drawing attached separately
Re�� o,� ( ousc�
A
13
2-1
I
3 O O
O
Z � Z
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t5ins•3m Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is
required for Cotuit Ma. 02635 1-16-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12'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: 1 Daatete
❑ 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:
Plan on file
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 17
A i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Danielle Street
Property Address
Paula Fullerton
Owner Owner's Name
information is
required for Cotuit Ma. 02635 1-16-15
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
....._.:.--
TOWN OF BARNSTABLE
LOC Zr� & dzu—�'J SEWAGE #
VILLAGE .�n ` ! , _ 64i SESSO Is,MAP & LOT 70-7
SPdZ R's` 09
NAME&PHONE NO o�
SEPTIC TANK CAPACITY 160r)
alk (size) ,100
LEACHING FACILITY:(type)
�� 0 ,
NO. OF BEDROOMS
BUILDER OR R
PERMITDATE: COMPLIANCE DATE:
Separation`Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland Leaching Facility (If any wells exist:
on site or within 210 feet of leaching facility) Feet
Edge of Wetland and Leaching.Facility (If any wetlands exist .
within 30 feet of leaching facility) Feet
Furnished by
= II
- � I
l jW �� ��
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fr
8
l
t� 1 �
oa � A.
BORTOLOTTI CONSTRUCTION,.INC. t W "r��s( ?19
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 T�49NTrge(F '98 `
508-171-9399 508428-8926 FAX: 508428=9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT[ON FO 'h�I
PART A _
CERTIFICATION
Property Address,
Date of Inspection: Inspecto ' Nafue:
Oyvjjets Name and Address:
c t
CERTIFICATION STATEMENT:
I certifytat I h
a
ve
personally inspected the sewage disposal system at this address and that the informs-
lion repotted below,is true,accurate and complete as of the time of inspection:l'he inspec,Kion was per-
formed based on my training and experience in the proper function and inainlenance.of on sit6.sewage
disposal,Aystems. The System: ;
t/' Passes
Conditionally Passes : .....,..., _ . .
' Needs rl Further 4voliation B th Local Aproving Authority
Fails a
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to tho,Appro!iiig authority�within thin
,
ty(30)days of completing this inspection:F`If the:systcir is a'shared'system or•h.,�a-design flow of 10,000
gpd oi`greater;the inspectoiand'the system owner shall submit the report to tlic.appropriate regional
office of the Department of Environmental Protection. The original should be YfeFtt to the system owner
and copies sent to the.buyer;if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYSTE PASSES:
I have not found any information which indicates that the ustem viaystes any of the failure
criteria as defined in 310 CMR 15.303, Any failure criteria not evaluated are indicated
below.
'B)SYSTEM,CONDITIONALLY PASSES; `
One or more system componerts need to be replaced or repaired. The system,upon eomple-
' ''tion of the replacement or repair, passes inspection.
Indicate yes,nor,or not determined(Y 1I uR ND).Describe basis'of determination in all instances. If
"not determined",explain:why not.
' y'The septic tank'is metal,cracked,structurally unsound,shows substantial infiltration or
t exfiltration,or tank failure is imminent. The system'will pass;inspection if the existing sep-
`tie tank is`replaced with a conforming septic tank as approveal b) he Board of Health.
i' Sewage backkup or.breakout or high static water level observed in the distribution box is due
- to broken or'obstructed pipe(s)or due to a b oken,settled=�r�aneveft distribution box. The
system will pass inspection if(with approval of The Board oVHeatih):'
-1 -
r
}eft+#'^ ;'�'^:� «.: W� Z �•i.:,i:[a �9. zr r��".�,.t}}u�''as P�.x �.s:: -bex) a r w::a A ,�
� �` e- i t E� � � h,"� 5���-�`5��. ��fw��i.S�` �ij"4 € �` •- k 'C ly ���1 il.{{ ��f�r"° 3kV..ir, ,:. .� �,<,` ..=v •. .+:..
-
,� � ��' ns)? R� �,:Y* NS' ��`e � �� at t'���.s^ t� �.*Uy�, " .�'�' a =—�• ? .,,r�r�����t.,������ � L
:,
mow,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION(continued)
Broken pipe(s)replaced .
dbstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broker}or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health): .
Broken pipe(s)are replaced
Obstruction is idmoved
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)SY$TEMsW. LL PASS UNLESS BOARD OF HEALTH DETERMINEBTHAT.THE
;,: ..SYSTEM,I&NOT FUNCTIONING IN A MANNER WHICH WILL,PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or priv36is within 50 Feet of a bordering vegetated wetland.or,a milt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF,HEALTH (AND J?UBLjC,WATER`%
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM LSIFUNCTION-
IN,G M MANNER^THAT PROTECT THE PUBLIC HEALTH AND$AFETY AND�THE
V ENIRONMENT.
'The system: 'sep tic tank and soil;absorption.iysfem and ismiddrx.100 Peet to a surface
_�. . 'Y "J.. r;N.,,i,§4�„ 1 :.: rf�gK�'wsJzi•ylt' E;.
water{supply or tributary to a surface water supply.
l i The system has a septic tank and soil absorption system and is with n Zoge I of a public l
-. :water.supply 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 is less,than 100feet butt*0;l
Feet or more from a private water supply well,unless a well water analysis for colifornt
bacteria and volatile organic compounds indicates that the well is freetom,poll!",#om
s the facility and the presence of ammonia nitrogen and nitneq,nitrogen Isi.equal yto orless
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CUR 15.303. The basis for this determination is identified below,=,Thp;p9a4of,I"lth
s�touldbe,contacted;to.determine whatwill be necessary to correct the failure
Backup of sewage into facility,or system component due to an overloaded or clogged SAS
or cesspool.
Discharge,or;ponding of efluent to the surface of the ground or surface waters due roan i
overloaded or clogged.SAS or cesspool. *°v
is ,Stat}cbquid level in the distribution box above outlet invert due[o an overloaded or log-
- t�
� Liq* depth,m cesspool is less than 6".below invert or available volume is less than 1/2
asy no F
Required pumping more than 4 times in the last year I W_,due tci clogged or obstructed
pipe(s).,Number of times pumped
2-
F
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy js below the high groundwater
elevation.
Any poidon 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 I of a public well. v
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;besacceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FARS:
The'foll"w ,criteria apply to a large system in addition to the criteria above
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a:s1officaut
S threat to public health:and safety and the environment because.one or more oftthe.followiu tp r,.'r
conditions exist
The system is within 400 Feet of a surface drinking water supply.,
The+system9is within 200 Feet.of a tributary o a surface drinking wa : '
f ,
The system is located in a nitrogen sensitive area Interim Wellhead Protection.Area;
,(IWPA)or a mapped Zone I1 of a public water supply well
The owner or operator of any suchaystem shall bring the system`and ii@l ty,into,fu114compliaucg4.withthe x
ry v
groundwatertreatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local,5
regional office of the Department for further information. `
�®K
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART B
CHECKLIST
Check if thefollowing have been done: ,. y
_Pumping information.was requested of the owner,occupant,and Board of Health
_None of the system components have been pumped for adeast two weeks and' a system j k, 5
been receiving normal flow rates during that period.',Large volumes;of water have,not been
4•p.Y,. ..:.
i introduced into the system recently or as part of this inspection.
Virr
As-built plans have been obtained and examined. Note if they are not available with,N/X
The facility or dwelling was inspected for signs of sewage back-up.
' he system does not receive'non=sanitary'or Industrial waste flow.
�Thesite',:was inspected for signs of breakout.
systemtgotnponents,excluding the Soil Absorption System,have been located on site
The septic tank manholes were uncovered,°opened;and the inters r o the septic¢tat s w�as�i
;. : spected.for condition of baflles..or tees,material of construction,dimensions,,depth of liq d,
i th of sludge,depth of scum.,` ; " ,<: i,,,¢raaz�,itt�Y.,•,��t;
y The size and4ocation of the Soil Absorption System on the site has been determined ba on
I.•i
existing information or approximated by not-intrusive methods.
-3-
�' ;:.' � ..,aw.y{,y �. 1 'r tMa* �€.4"�^4'2•es1� „°S s:;rva .a.,a"y'$ Y k'P
},� % f '3`'y9�..,z4 f$ 4i k.,��- p'J ,' .?'� Yt•.fjrrN{�z; ' yY .
�•� k"Y't. ��h'un x t 1 u 3 s t,s.. -t�;y '��r✓` -f?#x .J�. ,,-,.t ! .- '. ...,._ ' s,P'A .�, i.;;� � x �' '
�}x � "j t�,;��'sf 'c'�'�3•a� a, ,s"+` , a . " ' t .� i 5 �. � �4r,ty° ���''�'�� � x
Y
` 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " 4?
PART B
CHECKLIST(continued)
" '`"The facility owner(and occupants,if different from owner)were provided with information on
thp,proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL!
Design.Flow: Ilona Number of Bedrooms: Number of Current Residents QL
Garbage Grinder: Laundry Connected'I o System: _
Seasonal Use:�__
Water` itei','Readings 'aw(ableor 7
Last Date of Occupancy
;, DOM_MF.RCLAiJIND 1S 1AL,�(�'
Type of Establishment,`
K Design Flows' °i'i'"'"{�' lone/day,,'.Grease Trap Present:(yes'or no)
Industrial Waste Holding Tank'
Non-Sanitary-Waste'Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy;
i GENERAL INFORMATION
PUMPING RECORDS and'source of information:4
System Pumped as part of inspection:_ if yes,volume puctapxd.
Reason for'ptwping'
'Septic-Tank/Distribution
FY3TEM Box/Soil'Absorption System
Single ool
OverflowCepsspool
Privy
Shared System(If yes;attach previous inspection records;if any),
• Other(explain)
ROXIMATE'AGE' all co ponents,date installed if known)and-s6urcn Of.igg#mtion
Sewage odors detected wh arriving at the site: V °
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC'TANK:
Depth below grade: Material of Construction:
_zconcrete metal • '_ FRP_, Other,`y,
(explain):
Dimisiops: ' Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3✓-°�
Distance!from bottom of SCUM to bottom brbudet tee or baffle:
Comments.(recommendation for pumping,condition of inlet and outlet tees or es,depth of liquid
level in lion to utlet invert,structural integrity,ev' ence of leakage,etc
/i
//- a, t
GREASE TRAP: A.V
concrete metal FRP Other `
Material of Construction:
Depth I�elow Grade:.. _ _. _ —
(eXplain)
Dimensions: Scum Thickness: _
Distance from top of scum to top of outlet tee or baffle:
Comments:(recommendation'for pumping;condition of inlet and outlet tees o;°:baffles,'depth of ligwti i
level in.relation..to outlet.invert,structural integrity;evidence.of leakage,etc.)
TIGHT OR'HOLDING TANK: of
Depth Below Grade: Matenal Coustruction:_concrete_nietat_FRP_Other(explaut).
Dimensions:. Capacity: gallons Design Flow:_ alIonstday
Alarm Level
Comments:(condition ofinlet tee,condition of alarm and float switches,etc.)__
5 y
DJSTRIBUTION_BOX:_+� ,
Depth of liquid level above outlet invert:
Comments:(note if el and distribution is equal eviden of solids car over,evidence of 1 e into
or out of box,etc.)
�: IPu1VIP cHA1Ia; d. 7
Pump i5 in working order
Comments:(note condition of pumpchimber,condition of pumps'and appurtenances,etc.)
ems:-'h-, . ,-r•..�,� .".�,fr"<$-:t;�; r^'°.. tn?s;�w. . •<,'_" 'F.tr `:S v ��'� �d"`,1•� � rt ^��;"i'` ��Q'' } . ,+u� �� r� �"�',"fi'r'gS<k'�k ,. ' t..;..
1� 'a+.• fi4�Sr' '74A C 6 r :�` R4 .rw; 'f u :-�Y� ry_y� ,d��. ,#`c+rt����ei� 4��� .�..1,�� �m il � ����'� t ,.�'r l t 7. ; i r �'
•�_ "�' `•d tp� t.,x t r ' - - - - (<,h.rz nr�' '�:.! ram'.5',;3° �r��r4•n,
,
t
f ,
`SUBSURFACE SEWAGE DISPOSAL SYSTEM•INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
- SOEL ABSORPTION SYSTEM(SAS):
(Locate on;site plan,if possible;excavation not required,but may be approximated by non-intrusrvet
methods) If not determined to be present,explain:
W _ Leaching � lleries numbs }fr
leaching pits,number: ' Leaching chambers, number: g g$ r
Leaching trenches,number,length: h.
Leaching fields,:number,dimensions:
Overflow cesspool,number:
Comm nts:(note condition of soil,sig r of by ulic ilure lev of pondin cPndition of.vegetation,
'e '
i/ ll
17
jCESSPOOLS
Number'and configuration: ' Deput-top of liquid to inlet invert:
Depth ofs1olids.layer s ' '' Depth of scum layer: Dimensions of;Cesspool: i
Materials of construction: Indication of groundwater
Inflow( I must be pumped as part of inspection)
77
Comments:(note condition of soilk,signs of hydraulic failure, level of ponding,,condidon of vegetation,
etc.)
Materials 6f construction:" Dimensions:
Depth..of Solids: —
Comments:(note condition of soil,.signs of hydraulic failure,level of ponding,condition of.vegetation,
etc.)
s
_.._._._ _
-6-
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
rl 0 -
- ..l i•t. ... � it: �9 '1 is .t •, ` � 1! -
DEPTSTO GROUNDWATER: '
Depth to groundwater: Z Z Feet
Method of Determination or Approxi Lion: 1G l 1IAI.0141' G!'5
_7_
L C P Ira o SEWAGE PERMIT NO.
S4 ,
VILLAGE
INST -A LLE A E & ADDRESS
tG
BUILDER OR WNAR
' DATE PERMIT ISSD E D �� 8
DATE COMPLIANCE ISSUED
e
{ ��` �
_ � �� ��
�- =e:�
�:
..- . .. .� - ,n
�`
ii
T? . ........ Fim..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® ADF VH
......OF....
...................................................................
Appliration for Disposal Works Tonstrnrtinn Frrmit
Application is hereby made for a Permit to Construct ( A�®rRepair ( ) an Individual Sewage Disposal
System at:
.........-- �...../ .. TA .._ ..................................................
__...... .. . --.. ....
L�c tiqq� s Z
o Lot No.
.__._ ... Fes. .----•--• •.................. .•--•----.... ............
. ........ ..._
a ............i W ----- ---------------- -----------��...�✓ Pe-•--...------.. -----------
Installer Address
UType of Building Size Lot. �c --------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'_l Other—Type T e of Building ........ No. of persons............................ Showers
� YP g ------------------------------•-••---•-----P ( ) — Cafeteria ( )
Other fi e ----•--------------------•------------
--- -----
W Design Flow..•.......... . gallons per person per day. Total daily flow---------- . ................gallons.
WSeptic Tank—Liquid capaci �allons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. ................... Width_ Total Length_._......_.. __ Total leaching area....................sq. ft.
Seepage Pit No-------_�-...------- Diameter....... .----- Depth below inlet......,,,------. Total leaching are, ---sq. ft.
Z Other Distribution bbx ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................-_,__.
4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .._... ------....................
----••-..........
--------------------
0 Description of Soil..._. _l__..____l _____._._:__
........................................ ..........--------
- /
Nature of Rep4U s-or Iterations—Answer when applicable.................................................................................:.............
.•... •----•--•-••----------------••--•.....-••--...--•--•-----._..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITU 5 of the State Sanitary Code he u ersigned further agrees not to place the system in
operation until a Certificate of Compliance has be is e by oard of health.
��-"-�- gned.. • ................•••..............--•----- ............................... -•--/-...........
Dae..
Application Approved B � :.. •... --................. '!?r`..---------- ••--•-... ..=
7
to
Application Disapproved for the following reasons----------------------------------- .........................
........................................... . ---------- ----- •------------------
Permit No. .... •--• -----------•••• .... Issued_ ` '7---- Date
" ---------- - --_.�-_�_�__-----__-^-•-._._---_ Date-------------- -
• " .. _ .may '� .
• ._ 5
FEE............._...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F E TH
..
, r
OF... 50 ....................................................
, ppliration for Dispos I' orks Tonstrnr#inn .stub#
Application-is hereby'made for a Permit to Construct,( or Repair O an- Individual Sewage Disposal
System at , �°
.:..
LotNo
' W Vl P. w KWI .. .......... ........... ....�
Instal er . Address
" Type,of Buildirg Size Lot ..Sq. feet
U Dwelling'—No.,of Bedrooms.____.�- •---•--.--••-__ __._Expansion Attic ( ) Garbage Grinder
p, „ Other,-Type•of Building ............................ No. of persons..................•......:_. Showers ( ) — Cafeteria ( )
Other fi " •---------- ----------------
Design 'Flow............ __, __.----.-gallons per person per day. Total daily flow......... 1 .. :...:......gallons.
Septic Tank I:>quld'capac allons Length .......:.......Width .. Diameter................. Depth..._
Disposal Trench—'-'No> Width Total Length Total.leaching area - sq. ft.
Seepage P1t No:, Diameter_ _._ __.._.. Depth below.inlet___ :,....... Total`leaching ar =_sq. ft.
Z Other DisYi �ution box ( ) Dosing tank ( )
'-' Percolation Test,Results': Performed bY---------------------------------------------------------: •-
-• Date...........................
,.a. Test, Pit No 1..............minutes per inch Depth of Test Pit._.._.._...._...._._ Depth to ground water.
�-. ;.
(s, Test Pit No. 2................minutes per cinch Depth of Test Pit.......... Depth to ground water_..._•__...:'_t...................
a,.
. x Description of So>l --.............................................
_
V :................................................................ ..
W _
Nature of Re a"i�"s or�lterafions—Answer
t _
Uat...............................oP -- - when applicable -------------•-----------------------------•---•..... --•-•-•-•-••_.....-•----
Agreement:'
The undersigned agrees;'.to`install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TZTL% 5 of the State Sanitary Code The ersigned further agrees not to place the system in
operation until a'Certificate of,Compliance, has bee is e by board of health.
aw '� t. .
e._. �
Application Approved"B f 1 _._....: .............' .. - ate += kr
,Application Disapproved for the following reasons-..................................
........................................
4 k r d Date. ,
. mod'.. .y�' d.w
----
Permit No. -- Issued - .. :...........•-....
-•--------••-•---------- � Date ..,
_ x
_ - THE COMMONWEALTH OF MASSACHUSETTS .
BOARD F HEALTH
�,7�.......OF.... •2............................................... .:,......................
Trrtifiratr of fauntplianre
THIS IS TO CE That the ividua Sewage Disposal System constructed ( 'o Repaired ( )
bY-------------------------- ...�lk _ f'
_._
has been installed in accordance with the provisions of TITIF j of The State Sanitary Code as described in the
t
application for Disposal Works Construction Permit No : .=:_5. _______---,•. dated: .)"-"`_. ...-. —................
' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM, WILL FUNCTION SATISFACTORY.
DATE:- ... �$. �-
. .. Inspector ...: :..:...... ....--- •. �•----••--••--••-••••--••.....
THE COMMONWEALTH�OF MASSACHUSETTS
F BOARD O HEAL
+ • f -
r
1� ..O F......... FEE_ ..........
+ r .
No. .'..................
_ ..._.._.........
�iaposal n k n lerntit ,
Permission is h ranted...... ..... .._. . --•-
ll
to to, ( or. a air ( +) an dividual Sewa Dis Syst,
" Street �,,..as shown on the application for Disposal Works Construction Permit No.S _�°_____.Dated_: f / .................
ti Board of Health
DATE..... . .. ..-----? ...............................
-•-••.. ...........•--------
FORM 1255 A. M. SULKIN, INC., BOSTON - -
Al Z ,A .4
A10
//D X,3 = 330 G_Po.
SEAT C T,4.Vl� = 33aX/SO = 5`9S G.Ra.
BoTTotil,4.e�,.rl
w
T"OT.4L_ I�.4/L}�FLo1�t/= .330G•�onP
�E,f/G�t/.F�E.2GOL4T/a�V.�JT�•' /"/.v2ti//N oc�LE�"'� /a�,, • ' ``'�•
v�
fa,'i `' a -l.Ztl IvYj
4 ��ttChiAi1D
I so m a I ` N.O.24C
7-7
a Ili
7'Esr Nam � ,�' ,3�'�� 'GG�,�'.✓,.�.''/L,�•- .���. /t' '..�t c.:
/moo, �. F6• _ /oO.O r- �.. � �. �,•
6AC. /�Y✓� BOX /N✓. GAL, y� � �
`e, .SEPT�G
y. W!A-rti'EO :, q
.%�'`� �,� • • V TGNE yl�.�{ /"�•G CE,QT/F/EO PG OT PL4�✓ ;
LT
f L�f.V ,QE.�E.2F.t/oE
/ GE,eriFy Tf•',QT Th'E, ` ,%. r�� 5.�./o vciv
�...
/E�Ea.v G�iL1P�Y.S W/Try T,yE Si�E�,/NE 5.4X Z:,7e c/yE; /•vc.
4Mo SETI�Ac� ,eEQIJ�eEMENrs oc= THE /eEGisr�PtO A.ar✓o see✓Eyae S
TOyf/�v OF r ANV /.S NOT GiSTE.2l�/LLc a- �/,QS�.
A,C3al
T//lt 1-04�.v /.s .✓oT a.v A/v //YST,2-
.. . _. -�/.yE.YT,sver/�Yftvo T.vE o��s�rs
shl�K/�f/E,2E4/✓.5.4'o!/t-�/SOT!E USEp
Ta E.ST�l L/S/� Lar- I�NF�
i
1
1
L.0 CAI ION /,� SEWAGE PERMIT NO.
VILLAGE
I NST -A LLE 'S A E ADDRESS
� r 2 G
3
I U I L D E R ®R W. R
f
DATE PERMIT ISSUE ®
D A T E C0 M PLIANCE ISSUED
1
1'
NEw --T Is
2y`tz vr/
jE1v�7. 61.Fs5 i 4 ® RCl+�ovE 1�o ZT� OF o€�b� tdR
NEW CoNc. FzuNbA-n;N. ?W nLf+tll^
I R6
I '
` J W - '----- i Z---. ---- _._ Ex f-,Iwa 6 -DECK I -
34° C1Z Ifi)
5�9' O wOt-D p� .
IFIRELtaP ___. _
1=L,LL. j
TMNEW
I
3E 1
it; ADb �g i "Izn sz) I �E—Rcwkove wnu_ i
56Ll
,
L� I
-_I , ❑
Ca xeLoCA-lt cx•,cr
34
- �G,1 L1611
__—_—
Ex15T)t�la GR2k6,E
SUS✓414 CLM04T
SCALE: YL,", IFY wrrwovED er: aewww sr
co
OA""33 D rtnl 1 t E S
cx?rvl yvlA
_ � owwwaw wuwecw
Floss Fwo�2 �LA-N