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0058 DOGWOOD LANE - Health
58 DOGWOOD LANE, COTUIT A= 040125 LOCATION SEWAGE PERMIT NO. ZA4- // VILAG E Cc� Z- t InT A LLER'S NAME b AD RESS e U LDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 5a rot oo qq �J 39 3r' y4 -a -37 No. Y" D �' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete Syste�Individual Components Location Address or Lot No. 780 Z./� Owner's Nam ,Address,and Tel.No. ii>D I- Assessor's Map arcel , V __ �- 6L— Installer's Name,Address an�No. Designer's Name,Address,and Tel.No. • ski C,6, lA- T�pe of Building: Sae XckLk Dwelling No.of Bedrooms ` Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) &vd Design flow provided gpd Plan Date Nurlber o e is Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) fl ` F Date last inspected: Agreement: The undersigned agrees to ensure the cons do m i ten ce of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of th nviro ntal Cg e d to place the system in operation until a Certificate of Compliance has been issued by this Board corns Sign e' I I Date Application Approved by Date 7 Zd Application Disapproved by Date for the following reasons Permit No. 2-U Zo — 6 3U Date Issued l a 7 2U • t` r *�- �••-�- „ 1� - fir," ' +' No. <' f ( i� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.✓ Yes .PUBLIC HEALTH DIVISION -`TOWN OF BARNSTABLE, MASSACHUSETTS Application for Misposar 6pstem Construction j3erinit Application for a Permit to Construct(` ) Repair( ) Upgrade( Abandon( ) [:]Complete Systenj �lndividual Components. Location Address or Lot No. Wqp Owner's Name,Address,and Tel.No. Assessor's Map arcel CTni Installer's Name,Address and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) r�/ 1 r� d Design flow provided gpd 1 � Pf —'Plan Date ' N ber o is Revision Date .Title Size of Septic Tank Type of S.A.S. j Description of Soil Nature of Repairs or Alterations(Answer when applicable) Y ,4 ,,Date last inspected: ;`Agreement: y t The undersigned agrees to ensure the consttat do m i ten ce of the afore described on-site sewage disposal system in 1 t accordance with the provisions of Title 5 of the Environ ntal C L d f to place the system in operation until a Certificate of .,:Compliance has been issued by this Board of Health. r Nigne�d Date Application Approved by.. �r Date . ' Application Disapproved Date =for the following reasons, Permit No. OZ-o ' 0 30 Date Issued w --------------- y-- THE COMMONWEALTH OF MASSACHUSETTS 9 BARNSTABLE,MASSACHUSETTS Certificate of Compliance s LY THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by 'h"� �E r t e Ubeen constructed in accordance I with the provisions of Title 5 and the for Disposal System Construction Permit No.iO'a —03dated Installer {� ? Designer #bedrooms } �-' Approved design flow gpd ` 1 t The issuance of this pe it shall not be construed as a guarantee that the system wi/llfun\ction)as design/d. Date 0 '') j Inspector 1 1 w _, l•� , - -- �--------------- - - ----- - -` '' =v=�. -- --- - . ---- ---- No. G =-�' C7X t \ VNv Feed THE COMMONWEALTH 8F MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction i9ermit Permission is hereby granted to Construct( ) Repair(>< Upgrade( ) Abandon( ) System located at kxD0 L-t j and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 permit. / , 1 Date � /� ��� � Approved by Lv✓ Ott Town of Barnstable ti Inspectional Services 0396 ,� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4988 1135 January 2, 2020 POLIZZOTTI, MARIO A & GRACE M TRS 58 DOGWOOD LANE COTUIT, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 58 Dogwood Lane, Cotuit, MA was inspected on 12/18/2019 by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection,of the septic system showed that the system "Conditionally Passes" under the guidelines of 199.5 TITLE V (310 CMR 15.00) due to the following: e Need to replace the rotted distribution box and fix the piping: You are ordered to replace the distribution box within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH ,Thomas Mc Zan,, CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\58 Dogwood Lane Cotuit.doc of"T"E roy, Town of Barnstable • UA MMULE, "39 a 1679. Inspectional Services Department ��� AT fD MA'S� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 4 ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool o Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) o Leaching facility with standing liquid level at or above the invert pipe (per Town Code§360.-20 h) O ER On 1A U— bo t- f, Repair deadline: G,r Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts ©`/o'102� ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 58 Dogwood Ln. t.a Property Address f Polizzotti Owner information is Owner's e r 1 required for every COW.. Na MA 02635 12/18/19 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. A. Inspector Information /- Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 '(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12/18/19 Inspec ors Signatu 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 e ,r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ? 58 Dogwood Ln. Property Address POIiZZOtti Owner Owner's Name information is required for every COtuit MA 02635 12/18/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Dogwood Ln. Property Address PoliZZotti Owner Owner's Name information is required for every v Cotuit MA 02635 12/18/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 D-box is corroded and needs to be replaced. The line from the D-box to the leach pit depicted as "M on pg. 16 has an obstruction in it approximately 5' from the pit. The line is either crushed or has root intrusion to the point that I was unable to snake my camera through it and into the pit ❑ 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR i h 15.303 1 b that the system is not functioningin a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �a 58 Dogwood Ln. Property Address POIiZZOtti Owner Owners Name information is required for every Cotuit MA 02635 12/18/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 t Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •,_,, 58 Dogwood Ln. Property Address POI iZZOtti Owner Owner's Name information is required for every Cotuit MA 02635 12/18/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 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 water supply 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.] El ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �. (P Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Dogwood Ln. Property Address Polizzotti Owner Owner s Name information is required for every Cotuit MA 02635 12/18/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional'office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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? El El available 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �. IF Title 5 Official Inspection Form 15 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Dogwood Ln. Property Address POI iZZOtti Owner Owner's Name information is required for every Cotuit MA 02635 12/18/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: No engineering on file Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form (r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Dogwood Ln. Property Address Polizzotti Owner Owner's Name information is required for every Cotuit MA 02635 12/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Dogwood Ln. Property Address POI iZZOtti Owner Owner's Name information is required for every COtuit MA 02635 12/18/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1984 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 12" Depth below grade:. feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): >10' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Dogwood Ln. Property Address PoliZZotti Owner Owner's Name information is required for every Cotuit MA 02635 12/18/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-20 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): Pumping suggested at this time t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 . c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Dogwood Ln. Property Address PoliZZOtti Owner Owner's Name information is required for every Cotuit MA 02635 12/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 of 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.): 8. 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): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 ti Commonwealth of Massachusetts r= - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �a 58 Dogwood Ln. Property Address POIiZZOtti Owner Owner's Name information is required for every COtuit MA 02635 12/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): H-10 D-box is corroded and needs to be replaced. The pipe which serves pit"C" is slightly lower than the other outlet and all flow is going to pit"C"at this time t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments vV 58 Dogwood Ln. Property Address POIiZZOtti Owner Owner's Name information is required for every COtuit MA 02635 12/18/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: a t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 58 Dogwood Ln. Property Address PoliZZOtti Owner Owner's Name , information is required for every Cotuit MA 02635 12/18/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit"C" is in hydraulic failure at this time, effluent level is up and into the riser, the cover is 2" below grade. Pit"D" is dry at this time, sidewalls are clean, it is 2' below grade, cover raised to 12" of grade, the pipe serving it from the D-box is obstructed. I was unable to run my camera thru to the pit from the d-box, I suspect that there is either roots in the pipe or it is crushed 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 58 Dogwood Ln. Property Address POI iZZOtti Owner Owners Name information is required for every Cotuit MA 02635 12/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Tit le 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Dogwood Ln. Property Address PoliZZOtti Owner Owner's Name information is required for every COtuit MA 02635 12/18/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a 3� � t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 ti Commonwealth of Massachusetts 1� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Dogwood Ln. Property Address POI iZZotti Owner Owner's Name information is required for every COtuit MA 02635 12/18/19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: 14 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: n/a Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 4'seperation per 1984 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: The site is at 52'msl and nearby surface water is at 14'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Dogwood Ln. Property Address PoliZZOtti Owner information is Owner's Name required for every Cotuit MA 02635 12/18/19 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate a i 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 B©RTOLOTTI CONSTRUCTION INC. S� 3- �gbBB.UR?ACE SExAOE • DISPOSAL, BYBTEH INSPECTION YO" _ / -- — - Jlaer4s:e ot�property C� Ca te.''ot Ytspection PART :.A CHECKLIST .Cho :. if .the :Zollovi,nq have been done: k Pumpinq information was requested of the owner, occupant , and �Xone of the: system components "have been. pumped for at least t,-,o and ."the system has been receiving normal flow rates during tha - period. LaV1'9 volutses "o"Z water, have. not been introduced into the systems recent or-'as,;.part ,of this inspection . sbu"ilt pls �mve..be.en obtained and examined . Note f they , availbble: fa`ciitV :dwel`1"i'nq was inspected for signs of sewage hac}: The ■ite war x.0 zpected for signs o.f ` b.reakout . 1�11 system GQnp.0nents , excluding 'the ' SAS , have been located JL The septic t-A ffianholes were uncovered, o ened and the into .: the septic tank',vas : nspected:.for- Condi:tion. of baffles or tees saterial ,oi eonttruction,_ dim'ensions depth of liquid , depth o : scud i The =ize Arid Iocat;ion of the. -SAS on the site has been Bete*mince on �xtstinq inLormataon or. approxi mated: by non-intrusive methods 7t�e sac�.iYt owner y (anl `occupants, if. different from owner) � provided with information on :the proper:,maintenance of SSDS . SURSDRF.ACE ..'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS if residential— 3 number of bedrooms number of Curren residents' garbage 'grinder,: ,.yes or no' laundry connected ;to system,. yes--or no. seasonal `use �.. y i r nonresl'aent aY, "`calculated flow water meter readings, ;.if.,availabl'es Last date ' of' occupancy GENERAL INFORMATION Pumping. records .and source of information: �D'G✓/� Sir � i'P��i^�, Systein "pumped :as.. part of inspection, yes or no if yes,.:volume pumped Reason ,;.for pumping: TYP of Septic tank/distribution box/soil absorption Single cesspool p i n system vverYlO.w .cesspool Privy: Shared system (yes . or no)` (if yes, attach previous inspection `records ` .if' any) Other Jexpl"ain) APproxima.te age of all components Date 'installed, if known . Source of information: Sewage odors detected when arriving at the site es o . y r no _ _ ... 1111 8 UBB URPA ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC: TAN Kt /'560 (locate 'on . site plan) depth below. grade: �d material of: :construction: y Concrete metal FRP other(explairl) dimensions.: sludge .depth d{stadnc4::'from top of sludge to bottom of outlet tee or baffle p~ scum_ thfckness distance from ,top of scum to top of outlet tee or baffle distanoe from bottom of scum to bottom of outlet tee or baffle . Comments:. - -(recommendation for pumping, condition .of inlet and outlet tees or baffler., , depth of. :liqu id. level .In relation to outlet invert, structural integrity , e idence of <leakage, recommendations for epairs, etc. ) DISTRIBUTION< 80X: '(locate ..on site plan) depth- of liquid. level above. outlet invert eue Comments: (note if level':and distribution is . equal , evidence of solids carryover, evidence og leakage . into or out of box, reco endation for re airs , etc . ) / .; i PUMP . CHAMBER: " (locate on ,site' plan)_ pumps .in. working order, yes.-or no Comments:' (note. .condition of pump. .chamber, condition of pumps and appurtenances , recommendations for maintenance o e r r pairs, etc. ) SIIBsuR ACE ' BEWAGE. DISPOSAL-SYSTEM INSPECTION PORN :PART,.B. SYS,TEXXNYORMaTION continued SOIL ABSORPTION .:SYSTEM , (SAS). :_ (loeate .-on sits' plan', tt-;possible; excavation not required , but may be approx'imated.'-by., non intrusive methods) If. not determined -to be. present, explain: . Type . ono P¢t end rz" e-mb leaching. ch"bers ;,and number 1.eachinq:.galleries and -number. laaching trenches, number, length l each ing: ti�lds; number,. :dimensions _ overflows cesspool, 'number _._.. . Comments�s.. `(note condition:,of soil, si: n's 'of hydraulic failure, level of ponding , n .ition olvegetat orn, recommends ions for maintenance or epairs , etc . ) ZL T �. , INS i CESSPOOLS (locate 'on,,site plan) Q number and coal quration _..__. depth :'top of ';liquid ;"to ;;inlet invert depth of solids layer ,depth ot.� scum layer: _ dimensionsk of 'cesspool.< - matarials,To= .construction = - •;indf.cation o!r groundwater 1. inflow ( eaapool must !be, pumped ,as part of ins0eotion) Com�ents z not condition of soil, .,signs of hydraulic failure, level of ponding , con d.ition`=ot 'vegetation, 'recommendatons for maintenance or repairs , etc . ) PRIVY; , {locate `on site plan). K amaterial;s of construction t di�menaion8, --- '. . Comments: ..., (note condition of -soil', signs of hydraulic failure, level of ponding , condition of 'Vegetation,:: recommendations for maintenance Or repairs , etc . ) e... a. SUBSURFACE SEWAGE DZSPOSAL, B,YSTEK INSPECTION FORM PAR T B . - SYSTEM: IN.FOR TION continued :SKETCH OF :?.SEWAGE "DISPOSA . SYSTEM: include ties to 8t least tW0 permanent references landmarks Or benchmarks .locat`e all we7; s within 100 ' O. S i - DEPTHTO- GROUNDWATER depth ;_to. groundwater nathod of determination or.: approxfmation. • /obi 0ai© Te�w�� i ;80B80RFACE .SEWAGE DISPOSAL `SYSTEM ; SNBPECTION FORM PART C. `:. FAXLORE' :CRITERIA Zn,dicatw,,yes,,: no or not :determined (Y., N ' or .ND) . Describe basis of ,:determination,. in. all :`Ins tances., I! "not determined" , explain why not) Aackup o! sewage: into facility? Discharge or ponding .of _ effluent to the . surface of the ground or surface;waiers? ; Static liquid level in the .distri,bution box above outlet invert') Liquid depth in.:cesspool <6" below invert or available volume< 1/2 d,+ . flow?: Required: pukpinq.A times: or more. in 'the last year? number `,:ot:;:times: pumped : . .;Septic tank':is metal? cracked"? :s Y tructurall unsound? substantial infiltration? `subst ant 161 exfiltration?tank failure imminent? Is any portfon of the SAS, c.esspool .or. privy: . below the high groundwater elevation?. ` ;wit? :in 0 feet of a surface; water? ;., Within'. 100 feet: of. a .surface water. su 1 or tributary to a :.water supply:? supply y surface within a Zone of.:,a public well? within 5.0. feet,.of bordering vegetated wetland or salt marsh (cesspools and privies '.only, _ the SAS) ? within 50 feet of a private water su 1 well? ' PP Y less than 100 feet ,but greater ,than 50 feet from a private water ater supply ve11 'with :no :°acceptable water quality analysis?44: If the well has ;b4en ;analyzed` to.'be:' acceptable,.:.attach copy of well water analys for col ilorm ';bacteria, volatile :organic compounds, ammonia nitrogen ;and nitrate .nitrogen,: SUBSURFACE SEWAGE DISPOSAL. SYSTEX INSPECTION POM PART. :D CERTIFICATION Name of` inspector Y Com an NamiV Cons{Cc.C2r1, � . P Company; Address 7(D5— p1Y81 rnP- 11� rertif Ieation Statement S"Ti�T� TeX�t`l at `�}":.inspegl-t�'.':� tr+,:b, SeW3 .Q. d 5p`Sc�l System at tlii add=sss and that ahe iflfonaation iceported is true, accurate and complmte asof. ;the t nee of ;anspection. The inspection was performed and any raeommandati;ons regarding ,upgra'de, maintenance and repair are consit:t4i6t with`;'my. training,and ;:experience in the proper function and manitenance;:of ;on-s to sewage .`disposa1 systems. Chec�ne: �/ I have not found .inf indicates that the any ormation which system fail : toadsquately protect public health or the environment as defined in 310 CMR 15' 303 . ;. Any -la.ilure, 'criteria not . evaluated are as stated in the P1lILORE CRITERIA section of this form. I .<have:'determi"ned'.:.that ,:the system fails to protect public health anti the environment as :'de ined _ n 310 CMR 15. 303 . . The basis for thiF detetAination 'aa pro vid'ed . in :the FAILURE CRITERIA section of this ..inspector's> Sgnature Date Original to` .syst.em .owner Copies .to Buyer-:(If applicable) Approving.-,.:Authority Nc0`N'!'--Q,,�➢3 ti Fmc....° ............ r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -•----....................................O F......................................................... Appliration for UhipaaFal Works Tuntitrnrtinn ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal SysMtll.... at: ! --... ... Low&.L Cam:� ... ......... .. . . ...... ••-•••.•-_... ..... ' 1 Location. - ......r{ . ' Add^sG�`"rnIC. � t o `No .�....... ......+f----- ...----- .._ Owner Address Installer Address . Type of Building Size Lot............................Sq. feet �.. Dwelling—No. of Bedrooms.---- ...............................Expansion Attic ( ) Garbage Grinder ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P� Othe fixtures ------------•-- -••---••--•-... . W Design Flow________ ..................gallons per person per day. Total daily flow-----.---r`5�---•--•-._.._....._.._.gallons. Septic Tank—Liquid capacity....�� gallons Length................ Width_............. Diameter--.--.---------- Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.........---.---.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `-� Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit....--.............. Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........--............. ------------------------------------------------------------------------------------------------•---........................................................ Descriptionof Soil........................................................................................................................................................................ W UNature of Repairs or Alterations—Answer when applicable...................................................:............................................ ----••--•--•------•-•--•---•---•......-----•--•--------•--------•-•----------------•.....-••-•------•-•---------•------------•--•--•----------••.•----•--•----•••-•--••--•-------------............•--•• Agreement: The undersind agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the 0?' tificate 'LE 5 of the State Sanitary Code—The undersi n further agrees not to place the system in op tificate of Complianc has been issue bo health. Signe -•---- ----••---------••-•_...._d By-- --- -----•------.--••---•••-----••••--•--•----•-------••---------•---------------------- -- Date Appved or e f ollowi g reasons-------------------------------------•------------------•------•------------------------•--•---•-------....-•--•- --....-•-•-•--••------------••---.......-•---•-------••-•--•-•-----•------•--••----------------•----.... ..------•-------------•-------•----•--•-•-----•---..................-----... ......----•- Date ` Permit No________________ R Issued.....____.......__ ..----•-•--•-•--•------------•--• •--• .- --------••--------•---•----•• Date ^ .�� ±�r► ' ------------------------------—---------- ` - u a71 , Fps.. U THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ......... _ .................OF.......... ..... .-......... ....... Appliratiou for Bhipoii al Works Toustrurtiou .eruti# Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal Syritem at: CA ... ... Y............................................................. _.....--••-------•-•--- ••----- -• •••-•••.................. $ 41 41,qA Loc ttiot� Ad,ress Q , T t No f .- .--'-'---•- +a yd Owner ? j A res ......... ..................... •-- ........................................ Installer Address UType of Building Size Lot.................... .....Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder s ) a Other—T e of Building a Other—Type g ____________________________ No, of•persons............................: Showers ( ) — Cafeteria ( ) Oth • fixtures --------------• ------------------•-------•--- --------••----------•----------------------------•- - Flow------•` gallons P P P Y y -------------- Design W _-__�___�__________________ llons per person per day. Total daily flow.-._._-_:__________-______-_______._________ Ions. W Septic Tank—Liquid capacity_:__-_--___.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ....,................ Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( . ) aPercolation Test Results Performed by------ Date....................................... Test Pit No. 1________________minutes per inch Depth of Test Pit_--.-.____.-________ Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ OPi ..--•-----------------------------------------------------•------•---------.....-----'--•-••-•--••----•-._._....--'-----........-------•--•---•••--•-"•--•-- Description of Soil-=------•---------------------------------•--------...---------•-=•-------•--------•--------------`--------•-----------------------•--------------•-'--._.....---_----- U ------••-•-••-• ;� --------••---------------------------••-----•-'•------------...---------------------•------------------------------ V Nature of Repairs or Alterations—Answer when applicable............................................................................................... .---------•-----------•---••-•-------•-----------•-----------------------••------------•-----------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 4the provisions of T mLE 5 of the State Sanitary Code The undersi net further agrees not to place the system in f datt 'yy-/ry• Il`a ertificate of Comphan has been issued y h- boardHof health. �Sign ir_! _..-•-----------• _ _...•--cation Approved BY =----------' Date Plieation Disapprove for he following reasons---------------------------------------•----------------•------•-------------•--•------_.-...-------'-•--•- .._..••-•-----------------------•---•--_..._..---------------...••----------'----•...-----••----....----•---•-----------•-------------------•-------------------------------------------=--:::.--=-- Date . s ' PermitNo......................................................... >, Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH Trrtifiratr of fauutVii anu -y Tr, S I1F T CERTIFY, That the Individual Sewage Disposal System constructed -) or Repaired ( ) by.................... ..y,_._ ............. .. :._.............._.__........ 'P Installer has been installed in accord c with the provisions of TI�E 5 o e State Sanitary Code as described in the application for Disposal Worts' Construction Permit No............. _ _-_--._____ dated-__-----_..-.._--_._._---____________________ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE/CONSTRUAS A GUARANTEE THAT THE SYSTEM WNIL CTION SATISFACTORY.DATE..._..? f �1 . ... ..-----•--'---------=--•-- Inspector. ----- THE COMMONWEALTH OF MASSACHUSETTS BOARD Of9 HEALZ / - .......O F....... ... ........�wCe... '" No..1....................:. FE ................... i rr 1 urn Tonotrudiutt trout Permission is Y grage V`A'' ' ..- ....._...._ to Construct ( or Ir (»--}-an Indio dua� Sewage D1sp al Sy em"° at No. '►'....-•-•.. ----•- ' Street as shown on the application for Disposal Works C struction-:�PXrrrrit :_:____________ Dated.......................................... Board of Health DATE.._.. C% FORM 1255 A. M. SULKIN, INC., BOSTON. 7,"WE" -% I p% -51 qe.. W L TU 6AA:�AGa 642.1 IJ D3lz-. 'Ari1L•I FLOW i llauis- 55O +5O7o gET-Jr-tc rAl4i4 % 550 9'ZOO % Il ob U';8 2000 SAL. TAWld- "D151�sAt- F11T5 - 2- Icaoo /-Okl-J3 STb�4r= N moo�tiq Its '5F �41,o = 11 'S bflp 1 S1► 'TOTAL. 'Dm�lrs! v G1g><2• (3�GFD -TOr/A L p/�►I L ��oW ' 2 C' �PD \ / I oV� 32:/ 1 2�c..A'ftaN P-,4TQ II Iu 2 MIN oePer ( S• 1 � 5� r� l� _' i I � of \o '•,h�'jH 19q �P�tN Mqs p c , o Dnvlo ti R1�H ARD C. Lp A. THULIN / !<`: PAX7ER i No. 29976 �0�FS 5U - /0 Al E of To P FWD= `� Al �oov INS. b+N 42. D►ST. A l" St)wvI4. /L BVX �` SCPTIG 7. I.Ooo INY. l -rA►tK LEACH INV. INV. PIT w rr w �,-3/q•1 WA tpNGD GI..I�AN 67ON6 d4 (,nAV" t GERTIFtGD P►-oT PRUFIL L044'TI0N GoTv1T 1-Z NO SCALE SCALE ��=lop SATE 4-2-Ss�- No u/�Tt'ii= � Az�os I�-� p�p.I•� R E�E Q.E N GE i � GE RT 1't^Y ?•1.1AT '(N� t>Wlaa.•taNL 5No v�N NEB-Eo►,1 GOMPI-`�5 1n1lTH"CHE S 1 oELIN L oT I I A Q P 56T MEN7'> Cl - - '(oWN OI* 73Ar4.A41'rkr5LO At-ID 1S 140r L G P�Ai� S �oea(�� LOGp.TED •WtTN►�1 T 6 �Loo� F�l..o•lti! DA?E 4-Z-g,�. ('.t �r r B A�cT l�cZ a IJ`(E INC. R-E615'c E 26'D ►1it"1 D 5 u s�v E`(oZ5 -T%A15 PLa►`Q I '> N t3n5c D pid AN 06TELZVIL LE- I N5"rR-UM6NT SvQVeY( --THE- !?1:cTE-r'5 u� APPLICA►�Ir PI Noy' DE 'u5EDTo DETE`Z/^I►�t� L- 5 r! 2AG140r t�-AL .