HomeMy WebLinkAbout0011 JACKSON DRIVE - Health 11 Jackson Drive
Cotuit
A= 019 143
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i
Commonwealth of Massachusetts '
Title 5 Official Inspection Form f:
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w„ 11 Jackson Dr '
Property Address
Dave Hendricks
Owner Owner's Name
information is
required for Cotuit MA 02635 9-29-09
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.
A. General Information v�
1. Inspector.
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905* S13971
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: f _,
Q 0
® Passes ❑` Conditionally Passes `- ❑ 5'all
"" ` 0
f El Needs Fu r Ev. uati -rtf
on by the Local Approving Authority I
cr
9-29-09
Inspector's Sign re Date W rr
M
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall.submit the
report to the appropriate.regional.office of the DEP. The original should be sent to the system owner
and copies sent to.the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time'of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under .
the same or different conditions of use.
Lk
D
t5insp official document-03/08 Title 5.Official Inspection Form:Subsurface Sewage Disp al System-Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND)in the ❑for the following statements. If"not
determined,"please explain.,
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if.(with approval of Board of Health): -
❑ broken pipe(s) are replaced,,
❑ obstruction is removed
t5insp official document•03JD8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): }.
❑ distribution box is leveled or replaced
ND Explain: a
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which'require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or.the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water k'
❑ Cesspool or privysis within 50 feet of a bordering vegetated wetland or a salt marsh
' 2..System will fail unless the Board of Health (and Public water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
4
❑ The system has a septic tank and soil absorption-system (SAS) andithe;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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
13. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El ® 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 1/ day flow
El ® 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.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit t MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.): 1 f,
Yes No
❑ ® Any portion.of a cesspool or privy is within a Zone 1 of a public well
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
` ❑ ® Any-portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
-and chain of custody must be attached to this form.]
❑ ® The system is a Fcesspool 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 CM 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.
d
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 systetri,is within 400 feet%of a surface drinking water supply
❑ ❑ the,system is within 200 feet of a tributary to a surface drinking water supplyEl .
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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts l
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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 CM 15.302(5)]
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuitr MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 316 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
Number of current residents: : 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? x. ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ,,, ,;� ❑ Yes ® No
Last date of occupancy: 9-29-09
Date
Commercial/Industrial Flow Conditions: -
Type of Establishment:
Design flow(based-on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe): -
t5insp official document•03/08 Tiide.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Owner--Not pumped since new in 2005
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):
Approximate age of all components, date installed (if known) and source of information:
2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Jackson Dr
Property Address"
Dave Hendricks "
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code Date-of Inspection
D. System Information (cont.) A
Building Sewer(locate on site plan): `
Depth below grade: F t 24"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): ,
Distance from private water supply well or suction line: d feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: . 16"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:
- 1500ga1
Sludge depth: 12"
Distance from top of sludge to bottom of outlet tee or,baffle,, 20
1„
Scum thickness, ,
Distance:from..top of scum to top of outlet tee or baffle .6� -
Distance from bottom of scum to bottom of outlet tee or,baffle - 15"
How were dimensions determined? Tape
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 16-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
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.):
Tank is in good condition with baffles installed and no sign of leakage.
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.):
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):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 11 Jackson Dr
Property Address
Dave Hendricks F
Owner Owner's Name
information is.required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code_ Date of Inspection f•.
D. System Information (cont.)
Tight or Holding Tank(cont.) `
Dimensions:
Capacity:
gallons
Design Flow: = gallons"per day `
Alarm present: . ❑ Yes . ❑ No , t
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required)..Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.): l
Good condition with water at working'level:
Pump Chamber(locate on site plan):
Pumps in working order:. ti ,Y� ❑ Yes ❑ No.
Alarms in working order: ❑ Yes ❑ No
t5insp•official document•03/08 Title 5 Official Inspection Form:Subsurface Seviage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
2-500's
❑ 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.):
Leach chambers in good condition and empty at inspection. Stain line at 4"off bottom of chamber
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is Cotuit 'e MA 02635 9-29-09 r
required for
every page. City/Town, State Zip Code Date of Inspection ,
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration s '-
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer '
Dimensions of cesspool
Materials of construction ,
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids ,
Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,
etc.):
r
t5insp official document-03/08 , ._ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 16
Commonwealth of Massachusetts
r Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09 every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
.,l
A - p- IS- J.
37
® ° 6-D- 37g,r
t5insp official document-03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 11 Jackson Dr
Property Address
Dave Hendricks
Owner Owner's Name
information is required for Cotuit MA 02635 9-29-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Original design plans show no water at 12'.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
I
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/TOWN OF BARNSTABLE
LOCATION II�C 1� �J� SEWAGE # -------.--�._._
VIi:LAGE �O � 7— ASSESSOR'S MAP& LOT
ff4 NAME& PHONE NO.
SEP17C TANI{ CAPACrrY
r
LEAC G F'ACIL i Y: (type (size)
NO.OF'BE®ROOMS ._._.
BUILDER OR OWNER,
PERMI;T®ATE:. COWLL NCE DATE:
Separation Dista=Between tbe:
Maximum Adjustccl Groundwater Table to the Bottom of Leaching Facility Feel
Private Water Supply Well and Leaching Facility (1f any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and beaching Facility(If any wetlands exist
within 300 fe t f leaching facility) I�eet
FurctJ�hed by
14
A _ D. /
A F- i `
Fall
37 '
�� q3 `q
ii // TOWN OF BARNSTABLE
LOCATION II ,�G1CK ��D JA DV SEWAGE #Z00�+�D
VILLAGE Co t-lA ASSESSOR'S MAP & LOT �%'�C,or 3
INSTALLER'S NAME&PHONE NO.gnh 5 Ccuza4`o"
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 2 X 5?? (size) Z.5
NO.OF BEDROOMS
BUILDER OR OWNER If 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 an wetlands exist
8 g tY( Y
within 300 feet of leaching,facility) Feet
Furnished by �'
z �7 '3
03/27l2007 11:24 5084775313 ENGINEERING WORKS PAGE 01
Town of Barnstable
Regulatory Services
Tbomas F. Geller,Director
I 1 Public Health Division
Thomas McKesa,Direuaer
zoo Mato Street,Hyannis,MA 02601
Ofte- S08.862 4"4 Fait; M-79"304
installer Its-tr Corti
Date: 11 0f Sewage Permits$ ZOQ5-00 Assessor's MsplParcel �3
s (�tavc��-,Io,,1
Designer: �o✓� 1) Installer: n
Address: t2- W• CAT r S r�ekO�, (44 Address: 47 G o ac �¢V
On , o S f Zo n f- 'lax C-4ya+o'A was issued a permit to install a
(dam) (installer)
septic system at 11�u•+ Dr. G+y t' based on a desip drawn by
(address)
�v (rlc�vti�� dated ( �5 t fl`1 ''
(designer)
-44 I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank,
l certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or an), vertical relocation of any coznponant
of the septic system) but in accordance with Stare sit Local Regulations. Plan revision ar
certified as-built by designer to follow.
qN Oi
f Mead 1
(Installer's Signatm) ; ` .\ .; Wt
(Designer's Signature) (At�ix Designer's Stamp Here)
to nlymiON. CanTUICATY OF
lMCtr WILL NOT jL 5j1rn uNTIL AM JHJS JOBN AN
Q:Hwltivs0pticoolipa CenlBcation Pam']•26.(►a.ttoc
1
Town of Barnstable
�.1%E T°�+ti Re ulator Services
Regulatory
Thomas F. Geiler, Director
• snxxsrnaLE,
MASS. Public Health Division
AIFo ° Thomas McKean,Director
2,00 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: Sewage Permit# essor's Map\Parcel J02
20oS 00$
Designer: Installer: 6 w' sCpk,�14 F /
Address: Address: U'6 V3 6 / 7
h1&C �, rP b 6 V'
On o� /� t�S'— ow�S was issued a permit to install a
(date) > (installer)
septic system at �/ �' �0 L)�:�(� based on a design drawn by
(address)
dated
/ (designer)
y I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required).was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if required) was inspected and the soils
were found satisfactory.
r1l"-a
(Installer's Signature)
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 03-09-06.doc
No. � —(Tog - FEE / 5(:::�
'tCOMMONWEALTH OF MASSACHUSETT5
Board of Health, 1�6CYt-Sb�_ MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - AComplete System ❑Individual Components
Location () �0��' tA'SU,'1 � y Owner's Name `� ,� �Y�� ✓
Map/Parcel# MA 1C'1 FA_C_N 1 g 3 Address -M) �� Mrs, Do s,jo s, PA I gkg(}
Lot# Telephone# Zl✓�-'Zq-] .� -78
Installer's Name I G�Q AA i ic Designer's Name 7>e�cr Kc,C--A �446'" � S
Address (.c)��� Address
v �R V22b 1 z�L C cv s-C t2rJ� I 5
Telephone# - Telephone# f3 02-644
Type of Building 5 S t r a�d �"t �,' Lot Size 19 ✓�I® sq.ft.
Dwelling-No.of Bedrooms _75 Garbage grinder ( )
Other-Type of Building AU/A No.of persons Showers ( ),-Cafeteria ( )
Other Fixtures Nf Q
Design Flow (min.required) ?23d gpd Calculated design flow Design flow provided gpd
Plan: Dante E-1 1516 4 Number of sheets Zf— Revision Date-mil e4-
Title I�OhC(� .0�-l�C'u c of A t_�[AL,1�� / C ,�,/�,� -- A
Description of Soil(s) �3� /� t' (a-1 a3 /"'� -��^''1 yo 2 ���f' �/� J�1��! ► "'K S1. `
Soil Evaluator Form No. Name of Soil Evaluator A2-4pl/�'�� �_ tee Date of Evaluation n� )(! I AAL
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ee0 not lace a sys '91 in opera'on til a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
k
t. .Or W `�� ----!R xti t' „•\fir - r FEE?.1�9r. -WNW�ALT1111 OF MA
—
Board of Health, {'Y'Sfh�`� MA.
y \
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct,.),,-.Repair( ) Upgrade O Abandon( - Complete System� U Individual Components
Location Owner's Name ; L kQ h)Q «rrara '
_Map/Parcel# Mil J C% �p�r C9 i 143 Address 73A) So > 00 10 S 1 A 1 9-6 1
Lot# ,, Telephone#
Installer's Name /, s V �.� 1 Designer's Name�� n�o' ` WOY
f r�
Address " 0 c.)A C,e l ew, {2•b , Address) Z +N. C CL SS OA i2tA
Telephone#" - Telephone# �`-77 '" L`
tgqI 'Type of Building (2e S C�gyr�i c� t nq`f �`'1 y'�1 Lot Size 1 g.7(Q sq.ft.
Dwelling-No.of Bedrooms Garbage grinder ( )
Other-Type of Building /U/Pf No.of persons Showers ( ),Cafeteria ( )
Other Fixtures /VA �
Design Flow (min.required) `�3d gpd Calculated design flow 3--3d Design flow provided *3 1 ff gpd
I Plan: Date � � d Number of sheets �� Revision Date 9 3 16
Title �f[ Ohi!.� !C Svc�}fd`1 S i
Description of Soil(s)-F- 4'T// Q -3� /� 3 r0 - �„ , yo -/z— �S-4
1 ° Soil Evaluator Form No. Name of Soil Evaluator L-r/ Date of Evaluation ICI � A
Z
DESCRIPTION OF REPAIRS OR ALTERATIONS U 4
The undersigned agree to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthereet i not • rplace the cyst►in oper tion til a Certificate of Compliance has been issued by the Board of Health.
Signe —Date'
Inspections
r
f .
' No. �V ' ✓ FEE
C'®�l[MONWFALT14 ®F �'l[ASS#d S[TTS
Board of Health, c�(y�S+ b�e MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Component(s) Xcom�plete System
{
The undersigned hereby certify that the Sewage Disposal System; Constructed )6,Repaired ( ),Upgraded ( ),Abandoned ( )
by:
at 1 I ��c s�� �l`� �o (v4v,�
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.�(�S'� dated' �0�� _U App ved Design Flow (gpd)
'.
Installer
Designer: 1 Inspector: / • I 1G Date: IT
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No6900. 5 — FEE
k
COMMONWLA 114 OF MASSACHUSETTS
Board of Health,15Gr1V jiy bLe jMA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebytgranted to; Construct. Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ) 2ac c 5" f'. Co 4-\j I as described in the application for
Disposal System Construction Permit No.,�)00 5_C-0 y dated
Provided: Construction shall be completed within threeyears of the date`'of, is,per �'t. All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date I l 5/05 Board of Health` `' •—�
See �
NL� -2
V �
Town of Barnstable P# U �/
Epp THE
Department of Regulatory Services
DAMSTABM
Public Health Division Date / 7 D 3
9 MASS ° - -
cb 163q. 200 Main Street,Hyannis MA 02601
pTfD MAC A 7
Date Scheduled - 1 Q L t Time Fee Pd. 0 d
Soil Suitability Assessment for Sewage Disposal
rQ�
Performed By: R T'C� A(C-'C11 � / L' Witnessed By:
LOCATION & GENERAL INFORMAT ON. `
Location Address 4� Owner's Name �c.�� Vt\k P,r
Address ?4� SO JAO,;"� s-r
Assessor's Map/Parcel: `q ,e - Engineer's Name pp-� tAC
NEW CONSTRUCTION X REPAIR F Tel ephone# Sa@i 7-2--S: �l
Land Use (` & `�A( Slopes(%) E T -� Surface Stones ' /,Jo
Distances from: Open Water Body ft Possible Wet Area O =� ft Drinking Water Well L O ft
Drainage Way ft Property Line r ft Other
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
L
tea
Parent material(geologic) C i a��J f d�Mx/S'1 Depth to Bedrock 1 NCO
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater --�
Z
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.(tole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment R•
Index Well# Reading Date: index Well level Adj.factor Adj.Groundwater Level_
PERCOLATION TEST Date Dy Time (U:U'3 --
Observation
Hole# ,{QQ Time at 9"
Depth of Perc �6t''TU q Time at 6"
Start Pre-soak Time a
O Time(9"-6")
End Pre-soak AL e } M
' l
Ln
Rate Min./Inch .C 2 ` ^
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YM)
Original: Public Health Division Observation Hole Data To Be Completed on Back=----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:HEALTH/W P/PERCFORM
• L
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv
6 —►Z'1 L� l6 Y4l��A
3 tt— ZU �r 1'�e LW S-C'
DEEP OBSERVATION HOLE LOG Hole# 2—
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
621 A 1,S IC)\k4/l joIA
L S l o �
5CAvD&
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
Flood Insurance Rate Man: �(
Above 500 year flood boundary No_ Yes /
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occur-in>?Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on 1 (date)I have passed`the'soil evaluator examination approved by the
Department of Envirortmekial Protection and that the(above_ analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR15.01 7. a
Signature
Date l
Q:H EALTH/W P/PERCFO.RM
LEGEND School St
Benchmark set Pal
PK Hall set
AC f° f� E1.=100,00 (Assumed) ,rr ROOF RUNOFF SHALL BE
138 PROPOSED CONTOUR ooa Qp�IT
i f �, f DIRECTED TO A STAND PROPOSED SPOT GRADE
�' a
INFILTRATOR DRY UNIT 138
f6 Vic jfsQ SURROUNDED BY 2' OF STONE
" ~ '` AT LDCA,T1pNS SHOWN. __." 1(J„— EXISTING CONTOUR u
/el r - ,'' ,. w
r y r,. A`�I i.6 �� l E o EXISTING SPOT GRADE oc
TEST PIT o4 0� Ocean
jj
���� r1 ✓i eU�� QY"rr� ,20' W— PROPOSED WATER SERVICE h Bluff Point Dr
IF�rr 52°54, BVF%j LOCUS
h / F 10�,' J ' ,` 50 F�pN!I� ". l 'FLOW SURFACE DRAINAGE FLOW
FLO
,' f II b w LOCUS MAP N.T.S.
r f -� i r" r,• i
o� A
SEPNK' '> d �--� j GENERAL NOTES:
r r }
3 0 _. -
_ ,� ,•`• � �"'-- 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
_ �.,.�
BOARD OF HEALTH AND THE DESIGN ENGINEER.
54,3' r 'Y - rn, v� 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
,• r OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
Z15' 00 r 3 { - A, � � LOCAL RULES AND REGULATIONS.
IU r / r OS� ' r` .-_.._ T'T® \ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
N I y 43.6' PO G?`�k\ • ' c1 i saJQ r1 �� TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
(� Tf-2 f 3 S i i .' c�' ? 1 n :f 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
101.00 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
f / ��0•F �� r�g2,5 `„� t `" + ENGINEER BEFORE CONSTRUCTION CONTINUES.
1 10 13.2' ` ! L' S 2 r UR, 92. F cj \b I' S. ALL ELEVATIONS BASED ON ASSUMED DATUM.
O; t�*1 4 y� f LAR F r' UT r jER) \l�,t'Oa 6 i 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
CEL K $ARR v OI I + THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
F gA•5 j WAL TA'7IL 0 ^r r lJ f HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
41 - �' • { i cA ''\ ` 1 7. WATER SUPPLY PROVIDED BY TOWN WATER MAIN.
��Kw� PROPOSED S.A.S.
�� If+1 ;' ,. OF rr rg �'r ; I I '; ,a o �n, 1 8. THERE ARE NO PRIVATE WELLS WITHIN 150' OF THE PRO 0
L.
! IMj'� \ v._ { N W �' c
r% L \\ r 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO
O Jl� lil § + y.v� o I A CONDITION WHICH WILL MINIMIZE EROSION WITH PLANTINGS.
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
o CONSTRUCTION.
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
F '
✓' f' DP R T,_-_WALL i tZ*i IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S.
2 b! v ' �F M AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3).
EL. 9.5 ZONING CLASSIFICATION RF}BDTT. ELi EXISTINGfvG i `r l
`TNOFMASsq / ' ` + �' ��`°' �'�� PETER T, yG� FLOOD ZONE "C"DESIGNATION FROM
F9 ; \ A,/ RF1 Q t o I� " i `" COMMUNITY PANEL NO.250001 0021 D Aquifer Protection Overloy District
TERRY yGSF ' tf I-`a� ,1 ` ;� L h } MCENTEE = Revised July 2, 1992 Building Setbacks:
! j I \ ` O N
� w i � �`�' ' 4`.s`^� t 30 11 � CIVIL 30' Front, 15' Side/Reor
WARNER \�P rcEs1 14 , " ' \a' ISOLATED raj'G t
`s v i V �,�, il No, 35109 WETLAND DELINEATION BY:
No.38721 \ '.i i � VEGETATED ;t i" �'£G(S�ER�� ��`� LEC Environmental Consultants OWNER:
$ \ LOT t4 t t WETLAND x i \ } r FScIONA 3 Otis Park Drive Richard & Patricia Kohler
�4 4 t` w \2 t I Bourne, MA 02532 P.O. Box 608
SS�y S I 19,J`-IO is S.F. , } \ 0i f ON (508) 759-0050
15' _.; \ 0,45t 'QC, I o , .. j ` J l
Danboro,. PA 18916
(o ZI
1 b�
BLDG. SETBACK LINE (Tj � PLAN REVISIONS� �,�:, E ri� 't '''
9/13/04 - Revise Limit of Work boundary
PROPOSED SEPTIC SYSTEM SITE PLAN
\ 10
\ LN 11 JACKSON DRIVE, COTUIT, MA
\ N 37.09'50' W l moo, Prepared for: Richard Kohler, 341 South Main Street, Doylos, PA 18901
\ ;+ �) Engineering by: Surveying by: SCALE P.T.M.DRAWN JOB. NO.
07-04
\ E1Wnwdn9)F*r r Terry d. )FWx4vALS 1''=20'
t Q5, fl/ V\ 12 West Crossfield Road 22 Long Rood
\N v Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO.
4�' (508) 477-5313 (508) 432-8309 8/15/04 P.T.M. 1 Of 2
% „
A� TOP OF FOUNDATION NOTE: TO PREVENT BREAKOUT, THE PROPOSED
D SHALL NOT < EL:98.0
� F.G. EL: 100.8(MAX)
FINISH
GRADE BE
EL: 101.0 DISTANCE OF 15' AROUND THE
FOR A
F.G.EL: 100.3 F.G. EL: 101.Of �? I F.G. EL: 100.1 t PERIMETER OF THE S.A.S.
�- MAINTAIN 2% MIN SLOPE OVER S.A.S.
INSTALL RISER OVER CHAMBER/S
INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D-BOX T❑ 2- 00 GALLON LEACHING CHAMBERS
TO WITHIN 6" OF FINISH GRADE M WITHIN 6' OF FINISH GRADE , WITHIN
❑N PLAN AND SET C❑VER/S
IN SERIES WITH STONE ALL SIDES WITHIN 6' OF FINISH GRADE
L =16'
4' SCH 40 PVC
L 13'(MAX)
4" SCH 40 PVC 4" SCH 40 PVC 2° LAYER OF 1/8' TO 1/2'
e @ S= 2% CMINJ 7p ®® ®® DOUBLE WASHED STONE
@ S= 1% (MIN.) @ S= 1% (MIN.) Sam 00N
INV.EL: 98.55 a PROPOSED ® a®®
00 GALLON V.=97.80 INV. ELEV.=97.63 2' EFF. DEPTH, ��®�®®®
15 INV. ELE
3/4'-1 1/2'
x..�.,..
INV.EL: 98.35 SEPTIC TANK � 4' 5,2' 4' DOUBLE WASHED
FFECTIVE WIDTH = 13,2' STONE
INSTALL INLET &. OUTLET TEESV f INV. ELEV.=97.50
GAS BAFFLE TO BE INSTALLED ON INV.EL: 98.10
OUTLET TEE AS MANUFACTURED BY 1 TOP CONC. ELEV.=98.3 -BREAKOUT ELEV.=98.0
TUF-TITE, ZABEL, OR EQUAL MMME3 on
SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.=97,50 a®ae®
GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED
sm
STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). BOTTOM ELEV.=95.50 3, 2 x B.5' = 17.0' 3'
i
1 _
5' MIN, ABOVE BOTTOM OF EFFECTIVE LENGTH = 23.0'
T,P, EXCAVATION OR G.W.
SEPTIC SYSTEM PROFILE NO G.W. ENCOUNTERED LEACHING SYSTEM SECTION 1� �F Mgff
•
N.T.S. BOTTOM OF TP EL: 89.2 o PETER T.
(3) 5" DIA.OUTLETS J McENTEE H
CIVIL
16-_-�I NO. 35109
1 DESIGN CRITERIA A9�FS5j0 AL�4N�'���
15.5'
B"
6' L
' 10'-6" NUMBER OF BEDROOMS: 3 BEDROOMS
T 2' SOIL TYPE: CLASS 1 0 21
DESIGN PERCOLATION RATE: 2 MIN./IN.
-BOX 3 - 20" Dia. Covers i
* f SOIL LOG DAILY FLOW: 330 G.P.D.
Kt& DESIGN FLOW: 330 G.P.D
5'-8" O DATE: MARCH 10. 2004 to, 51 Z- GARBAGE GRINDER: NO
SOIL EVALUATOR: PETER T. MCENTEE P.E., C.S.E. LEACHING AREA REQUIRED: (330) = 445.9 S.F.
INSPECTOR: � DAVID STANTON -BARNSTABLE B.O.H.
.74
Elev. TP-1 Depth Elev. TP-2 Depth PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY
CE
® ® ®®®® Top View 101.3 A 0" 99.7 A0..
®®®®�®®® 33" YSANDLOAMY SAND®®®®®®®® LAM 4/1 10YR 4/1USE 2-500 GALLON LEACHING CHAMBERS IN SERIES
INVERT 10YR24" ®®®®®®®® 4" Dia. Inlets 4" 4" Dia. Outlets 100.3 B 12' gg.2 B 6'
LOAMY SAND SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F.
' 10YR 4/6 LOAMY
4/6 D
102" O " 98.3 C C I 36" 96.7 36" BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F.
TOTAL AREA: 448.4 S.F.
4" KNOCKOUT 36"
20' DIA, COVER 5'-8" 4'-7' 48" Liquid Level 4'-4" PERC DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D.
4$"
4" KNOCKOUT O 4" KNOCKOUT B2" 4.. 3.. MEDIUM MEDIUM
SAND SAND PROPOSED SEPTIC SYSTEM/SITE PLAN
4" KNOCKOUT
2.5Y6/8 2.5Y6/8 11 JACKSON DRIVE, COTUIT, MA
91.3
Section 1120 1 89.2 126" Prepared for: Richard Kohler, 341 South Main Street, Doylos, PA 18901
1500 GALLON CAPACITY, H-10 LOADING NO G.W. ENCOUNTERED Engineering by: Surveying by: SCALE DRAWN JOB. NO,
500 GALLON CAPACITY, H-10 LOADING
SEPTIC TANK PERc RATE < 2 MIN/IN. E/18)pB@/�/IgWOTib' Terry l�ornerP.L.�£ NTS P.T.M. 07-04
CHAMBERS 12 West Crossfield Road 22 Long Road
HTs. f Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET N0.
RT.s.
�� (508) 477-5313 _(508) 432-8309 8/15/04 P.T.M. 2 Of 2
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