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HomeMy WebLinkAbout0060 WESTBURY WAY - Health 60 Westbury OCL4iCotuit A= 011-065 — 1 f � i Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F i '' 60 Westbury Way ¢, Property Address NJ y Karen Haskins + Owner Owner's Na e ; 4 information is required for every Cotult 7 Ma. 02635 07_=03-2019 . page. , City/Town State Zip Code Date.of Inspection r 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 forma Important:When — t6 filling out forms A. Inspector Information 410&3 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector ! ;i l• ;' �. cursor-do not use the return Cape Septic Inspections key. Company Name G 52 Rivers End Road "ICI Company Address Teaticket Ma. 02536 t City/Town State Zip Code r 508-280-3356 S13938 Telephone Number License Number t a B. Certification I certifythat: I am a DEP a i approved system inspector in 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 u inspection; and the inspection was performed based on my training and experience in the proper function y, and maintenance of on-site sewage disposal systems. After conducting this inspection) have determined that the system: l 1. ® Passes 2. ❑ Conditionally Passes j 3. ❑ Needs Further Evaluation by the Local Approving Authority. 4. ❑ Fails t,L 07-07-2019 Inspector's Signature Date j 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 i { 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate i regional office of the DER The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i 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 a .1 , Commonwealth of Massachusetts Title 5 Official Inspection Form 'f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I K I 60 Westbury Way I Property Address Karen Haskins ; Owner Owner's Name information is required for every Cotuit Ma. 02635 07-03-2019 "` l page. City/Town State Zip Code Date of Inspection Co Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: f Z 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. # i Comments: This 3 bedroom home has a H-10 1000 gallon septic tank and a H=10 D-Box feeding a precast leaching pit and 2 leaching chambers. At the time of the inspection the leaching was dry and there, were no visible signs of past hydraulic failure in the leaching,' chamber I view with a camera I 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 a roved E the Board of Health, will pass. pp " j1 '; YI Check the box for es no or not determined Y N ND for the following Y ( ) o g statements. If not determined," please explain. , The septic tank i � �� u i p s metal and over 20 years old or the septic tank(whether metal or not) Is str'u�ctu;rall. I unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will:p�ss'i" inspection if the existing tank is replaced with a complying septic tank as approved by the Board of I Health. l r *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. r 1, t . ❑ Y ❑ N ❑ ND (Explain below): 1 al f ' j I t5insP.do c 6/2 rev.7/ 2018 Title 5 Official Inspection Form:Subsurface Sewa a Disposal sal S stem Page 2 of 18 P 9 P Sy stern I J , ' r ' c t Commonwealth of Massachusetts I I �n Ip Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System form - Not for Voluntary Assessments , 60 Westbury Way Property Address Karen Haskins Owner Owner's Name G information is required for every Cotuit Ma. 02635 07-03-2019 page. City/Town State Zip Code Date of Inspection G C. Inspection Summary.(cont.) p � 2) System Conditionally Passes (cont.): { El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. j ❑ 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)- I r r"F.• t� El obstruction is removed El. Y ❑ N El ND (Explain below) ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below)- i ,i ❑ 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): I �, ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below) _ cA - ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below) C . f 3) . Further Evaluation is Required by the Board of Health: I ❑ 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: I a. 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 protectpublic health,i safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 e ' f Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Westbury Way V Property Address Karen Haskins r. Owner Owner's Name information is i required for every Cotuit Ma.: 02635 07-03-2019 page. Cityrrown State Zip Code Date of Inspection Co Inspection Summary (cont.) ' It ❑ Cesspool or privy is within 50 feet of a surface water #+ P4 ❑ 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 i 100 feet of a surface water supply or tributary to a surface water supply. k ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a'public water G F4 supply ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private virater� 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 k 3} 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 forma l c. Other: 4) System Failure Criteria Applicable to All Systems: �4 You must indicate"Yes" or"No" to each of the.following for all inspections: Yes No i• El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 0 p ' i l Commonwealth of Massachusetts Ip Title 5 Official Inspection Form - 1 Subsurface Sewage Disposal System Form Not for Voluntary.Assessments 60 Westbury Way. I u Property Address j Karen Haskins h Owner Owner's Name information is '> required for every Cotuit Ma: 02635 07-03-2019 ' page. Cityrrown State Zip Code Date.of.Inspection: ' C. Inspection Summary (cont.) °4) System failure Criteria Applicable to All Systems: (cont.) Yes No I' El ® Static liquid level in the distribution box above outlet invert due to an overloaded, or clogged SAS or cesspool . I' ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less ,... than 1/day flow El 0 Required pumping more than 4 times in the last year NOT due to clogged or, obstructed pipe(s). Number of times pumped` „ ' r. 1 ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.:; ❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply l well: • I ; ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well a ❑ ® Any portion of a cesspool or privy isrless than 100 feet but greater than 50 feet 1,1 a 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, . ' t provided that no other failure criteria are triggered. A copy of the analysis' and chain of custody must be attached to this form.] ' { l a ❑ ® The system is a cesspool serving a facility with a design flow'of 2000 gpd- 10,000 gpd. 0 ® 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 +; t necessary to correct the failure. ! 5) Large Systems: To be considered a large system the system must serve a facility with a j, design flow of 10,000 gpd to 15,000 gpd. o , fi For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the u questions in Section CA. Yes No - I1 ❑ ❑ 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,,, ❑ Elthe system is located in a nitrogen sensitive area(Interim Wellhead Protection , Area—IWPA) or a mapped Zone II of a public water supply.well j }. 3, 1: ,.l t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 s fl I ; Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Westbury Way Property Address ! Karen Haskins { Owner Owner's Name t information is Cotuit Ma. 02635 07-03-2019 I`required for every L. page. CitylTown 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. t ' 6. You must indicate "yes" or"no" for each of the following.for all inspections: Yes No ! . a� ® ❑ Pumping information was provided by the owner, occupant, or Board of Health i jj ❑ ® 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? �l ❑ ® Have large volumes of water been introduced to the system recently or as�parfiofi this inspection? ® ❑ r 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? I ► ,. � Ili ® ❑ Was the site inspected for signs of break out? i h �j! ® ❑ 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, i dimensions, depth of liquid, depth of sludge and depth of scum? 0 . ® ❑ ;, Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems.i I The size and location of the Soil Absorption System (SAS) on the site has!; been determined based on: ® ❑ t Existing information. For example, a plan at the Board of Health. i f III ® .1 Determined in the field (if any of the failure criteria related to Part C is at issue El ill approximation of distance is unacceptable) [310 CMR 15.302(5)] , ° T�i 1. ! e t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18, t , Commonwealth of Massachusetts - Title 5 Official Inspection Form € a� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Westbury Way {; Property Address i .Karen Haskins Owner Owner's Name information is required for every Cotuit Ma: 02635 07-03-2019 page. City/Town State Zip Code Date of Inspection . I D. System Information 1. Residential Flow Conditions: , f Number of bedrooms (design): 3 Number.of bedrooms (actual): 3 ii. III 330 plus DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): GP i, Description: { i!, 0 ii a Number of current residents: F Does residence have a garbage grinder? ; ❑ Yes ® , No, Does residence have a water treatment unit? ❑ Yes ® Nos If yes, discharges to: ' Is laundry on a separate sewage system? (Include laundry system inspection . ; 'i f{I information in this report.) El Yes ® No a� Laundry system inspected? El Yes ®; No�' 1 i Seasonal use? El: Yes ®' No! Water meter readings, if available.(last 2 years usage(gpd)): , Detail: ---Ln ao I - { Irj b0� 1�O a c� .� 4 r U c cal n � 6 7 � �•I 1 0� �S C�Be Sump pump? El Yes Zt No , Last date of occupancy: Feb 2019 ; Date 3 r I( { i Ili 1 ; t5insp.doc-rev.7/26/2018 ill. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 y I I , Commonwealth of Massachusetts i !� Title 5 Official' Inspection Form 4 k r Subsurface Sewage Disposal System Form Not for Voluntary Assessments, 60 Westbury Wayi Property Address t i ,t Karen Haskins , 4' Owner Owner's Name i information is f � required for every Cotuit Ma: 02635 07-03-2019 I 9' page. City/Town State Zip Code Date of Inspection : 3 D. System Information (cont.)- , 2. Commercial/Industrial Flow Conditions: „ 1 Type of Establishment: 1 . 1 I Design flow.(based on 310 CMR 15.203): l!iitGallons per day(9Pd) t Basis of design flow(seats/persons/sq.ft., etc.); • i 1, Grease trap present? ❑ Yes ,❑ No j Water treatment unit present? ❑ Yes ❑ +Noh' ti II. k If yes, discharges to: Industrial waste holding tank present? F [I Yes ❑ No1 ll i Non-sanitary waste discharged to the Title 5 system? ,i',' El Yes ;❑ NoIl!> Water meter readings, if available: ' .1 �l Last date of occupancy/use: Date ! Other(describe below): 3. Pumping Records: ,I Source of information: ! Was system pumped as part of the inspection? El Yes ® No: If yes, volume pumped: gallons k, How was quantity,pumped determined? Reason for pumpin jg: f t5insp.doc-rev.7/26/2018 N Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 j I I i �)R `; I 1 • i {i 1 . _ $ �I ?' r 1 �fll Commonwealth of Massachusetts ' . Title .5 Official Inspection Form � p I � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Westbury Way u� Property Address Karen Haskins t Owner Owner's Name information is # Ij required for every Cotuit Ma. 02635. 07-03-2019 page. City/Town State Zip Code Date of Inspection Ij i yl D. System Information (cont.) d 4. Type of System:, I� ® Septic tank, distribution box, soil absorption system ;, . I A 11 ❑ �r ICI 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 'I 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 ageof all components, date installed (if known) and source ofRinformation- unknown Were sewage odors detected when arriving at the site? ❑ Yes ® Nol i l 5. Building Sewer(locate on site plan): 30 � ti I; �l', Depth below grade:. feet Material of construction: I ❑ cast iron:. f. R{ ®40 PVC ❑ other(explain): t r town water Distance from private water supply well or suction line: feet I Et i Comments(on condition of•joints, venting, evidence.of leakage, etc. : a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i II d I f I 1 � + -�: Commonwealth of Massachusetts Title 5 Official Inspection Form , f Subsurface Sewage Disposal System Form Not for Voluntary_Assessments I 60 Westbury Way J Property Address Karen Haskins Owner Owner's Name w information is Cotuit Ma. 02635 07-03-2019 required for every 1 , page. Cityrrown State Zip Code 'Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): �I { Depth below grade: 20 '4 11 P feet � , �� i0 I Material of construction: {' ®concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(expIIal1h) i tl If tank is metal, list age: years k{ r � j Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ,-i No r standard H-10 1000 gallon{ i Dimensions: Sludge depth: 11 Distance from top of sludge to bottom of outlet tee or baffle 30 I j 1 i , Scum thickness' i .,. 2,1 Distance from top of's 5��cum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1211 How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural i htegni�y,l'., liquid levels as related to-outlet invert, evidence of leakage, etc.): recommend the new owner have the tank pumped and then put the tank on a maint. plan with.a. local septic pumping:co. based on the future use of the home. The liquid level was at workingIlex+el:; �!I iFk itt 1 i fv Ij I I t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 " I} t I` Commonwealth of Massachusetts it i Title 5-Official Inspection Form ale Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 60 Westbury Way iE ' Property Address (i il• Karen Haskins Owner Owner's Name r� t information is ,. required for every Cotuit Ma. . 02635 07-03-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate,on site plan): r t t I i Depth below grader feet i Material of construction. F ❑ concrete ,❑ metal tI❑ fiberglass ❑ polyethylene ❑ other(explain)'' j ! w. Dimensions: n , Scum thickness Distance from top of scum to top of outlet tee or baffle a Distance from bottom.of scum to bottom of outlet tee or baffle` Date of last pumping: lilt Date ( I t Comments (on pumping recommendations, inlet and outlet tee.or baffle condition, structural integrity,1 liquid levels as relatedto outlet invert, evidence of leakage, etc.): ' 1 i . I 8.. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on.site Depth below grade:,; , It Material of construction: ❑concrete 010 metal ❑.fiberglass ❑ polyethylene,. ❑ other(explain)i! t �•., 'i1 ��� i ie t Dimensions: r Capacity: gallons Design FIOW: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 jl ii • i, II Commonwealth of Massachusetts Title 5 Official Inspection Form E I � Subsurface Sewage Disposal System Form- Not for Voluntary Assessments c 60 Westbury Way u Property Address t ` Karen Haskins Owner Owner's Name information is j ! I required for every Cotuit Ma., 02635 07-03-2019 page. City/Town State Zip Code Date of Inspection II D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes 0 N0 I " Ia Date of last pumping. . Date r Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached?. ❑ Yes U1 No 9. Distribution Box (if present must be opened) (locate on site plan): , Depth of liquid level above outlet invertlid Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover„1a( evidence of leakage into or out of box, etc.): iF At the time of the inspection there were no visible signs of leakage. # li i i f I ' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of I ai L E Commonwealth of Massachusetts Title 5 Official Inspection Form - , Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 60 Westbury Way (Property Address Karen Haskins Owner Owner's Name l� information is required for every Cotuit Ma. 02635 07-03-2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 1 ' 10. Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes ❑ No t ' • t pii i ' 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. i l 11. Soil Absorption System (SAS) (locate on site plan,excavation not required): a y ! y If SAS not located, explain why:. i , • Type: ® leaching pits number: one � flit ® leaching chambers number: t, 1( i� ❑ leaching galleries k number: r ; f ❑ leaching trenches number, length: , i lil '` { ❑ leaching fields number,dimensions: ❑ overflow cesspool number: { ��f ❑. innovative/alternative system Type/name of technology: € { R t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection ; p ctwn Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts / - 1 1p Title 5 ..Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments k f 60 Westbury Way Property Address $ �I Karen Haskins Ill 9� Owner Owner's Name information is 3 { Cotuit required for every Ma: 02635 07-03-2019 1? page. City/Town State Zip Code Date of.Inspection D. System,Information cont. ' ! • (cont.), i 11. Soil Absorption System (SAS) (cont.) I i Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r AT the timezof the inspection the leaching was dry. t i ' { I 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration' to—Depth fliquidl °a p p o to Inlet Invert Depth of solids layer Depth of scum layer I Dimensions of cesspool Materials of construction r � Indication of groundwater inflow ❑ Yes ❑ No i. i Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of veg a tatio etc.): r I • t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 1i; Commonwealth of Massachusetts IF Title 5 Official Inspection Form p . I Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments rI d 60 Westbury Way Property Address Karen Haskins { Owner Owner's Name t information is Cotuit Ma. 02635 07-03-2019 required for every ; . page. CityTrown State Zip Code Date of Inspection i Do System Information (cont.) 13. Privy(locate on site plan): i Materials of construction: Dimensions �. I Depth of solids_` " '1 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, I i etc.): t �a� cif �. F It �I - a f i , f •. ��- ' � l. it i I i , t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18' i r y . Commonwealth"of Massachusetts t iI i y�• G� `L I� Title 5 Official Inspection Form �j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 60 Westbury Way , Property Address I Karen Haskins Owner Owner's Name information is required for every Cotuit Ma. 02635 07-03-2019 page. City/Town State Zip Code Date of Inspection b ;' D. System Information (cont.) 14. Sketch Of Sewage Disposal System: 'g Provide a view of the sewage disposal system, including ties to at least two permanent refereh ce' h landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: R ® hand-sketch in the area below o f ❑ drawing attached separately R l iv� a2 3 ,y14 3 - 3y6" tg t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 4 I j Commonwealth of Massachusetts; Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;. fi I 60 Westbury Way Property Address Karen Haskins } Owner Owner's Name information is C r y required for every Cotuit Ma. 02635 07-03-2019 page. Cityrrown State Zip Code Date of Inspection {; { D. System Information (cont.) 15. Site Exam: i ® Check Slope f Surface ® u ace water � ® Check cellar I ® Shallow wells ( i 14 plus feet :t' Estimated depth to high ground water: feet q ' 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 1 1 ] I ® Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain:. Checked with local excavators, - ❑ ca ators, installers (attach documentation) ❑ Accessed USGS database-explain: ' You must describe how you established the high ground water elevation: 1. I augered a hole at a lower elevation and I shot it with a transit to show four plus feet of sepeiration' j ` Before filing this Inspection Report, please see Report Cm ist onnetopleteness Checkl x p'a'ge. t5insp.doc •rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18' Commonwealth of Massachusetts �n Title 5 Official Inspection Forms 1 ' la Subsurface Sewage'Disposal System Form - Not for Vol untary.Assessments 60 Westbury Way Property Address Karen Haskins ¢ Owner Owner's Name u} information is {{ y tuit Ma. 02635. 07-03-2019 required for every Co r! I page. City/Town State Zip Code. Date of Inspection ( l 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 4!3 1 L ` 4 (Failure Criteria)and 6 (Checklist)completed. } ® Q. System Information: For 8: Tight/Holding Tank=Pumping contract attached _ I. For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included L it i • E 3 fi 'f, �. t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18; TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 0 a2-d6-� INSTALLER'S NAME&PHONE NO. PtE34Z SEPTIC TANK CAPACITY I D Oe2 ca,. LEACHING FACILITY: (size) NO.OF BEDROOMS 2 BUILDER OR OWNER PERMTTDATE: -7 ` '1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by `_ � ,� O .3 �' � I �2 :2� � d32 No. � t ,., . --• Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Digpogal *pgtem (Congtruction Permit O� Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. CO (,0(2�576vy (fo-'TO 1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel �c�v moo✓ k4c-_1 (i:tis 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Q Type of S.A.S. 6 Ic2Y S� tr �c��Dlr`P Description of Soil Nature of Repairs or Alterations(Answer when applicable) %000 Die= GwS-r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co and no-to place the system in operation until a Certifi- cate of Compliance has been issued b this Bo of_Heal h. Signe Date +�'c3 Application Approved by ® Date Application Disapproved for the following reaso Permit No. Date Issued C-A7 IT 5 No. _ ' Fee I ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Mizpogar bpgtem Conotruction Permit 0 � Application for a Permit to Construct(, )Repair(VI)"Upgrade( )Abandon( ) ❑Complete_System ❑Individual Components Location Address or Lot No.60 (JEST 6j yJ (,,,owl( Owner's Name,Address(t and Tel.No. ir Assessor's Map/Parcel, . / �, Gv c ti . ,�1�•Si vt Y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank c A06 y�5 Type of S.A.S. h X(rLOyc -cF4s1" tr �S�l Description of Soil `M G p SSA Nature of Repairs or Alterations(Answer when ap licable) Q�o� p—Q 1c i . r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental CoOp and not.to place the system in operation until a Certifi- cate of Compliance has been issued b this Bo of Hea h. Signed k Date Application Approved by © Date Application Disapproved for the'.following reaso 6 Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS. G BARNSTABLE, MASSACHUSETTS Certificate of (compliance THIS IS TO CERTIFY, th t the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded Abandoned( _)by 6 S V\A"D-(-Nr=S-P ,C_ at S\ liouv V i hasibeen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer. The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date '_1 — 7 I Inspector i i III -----% -- ------------------- No. Fee V y THE COMMONWEALTH OF MASSACHUSETTS j . PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopozal 6pot �ggrade onotruCt on Permit Permission is hereby granted to Construct( )Repair ( )AbandonSystem located at o (w� S� �/ t�_0� f_C)4v+\ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.. Provided: Construction mus be co rpleted within three years of the date of this its U Date: ;--"j / �7r Approved by (i� I[ �. ii ! f y TOWN OF BARNSTABLE LOCATION UV SEWAGE # VILLAGE �� J ASSESSOR'S MAP& LOT ®oZ 7-065' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (1 (size) 00c) NO.OF BEDROOMS 2 BUILDER OR OWNER I C��, a., � � A„ PERMPTDATE: —a-7 - 2 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by IL l.. 2 oil, bUL) NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated c- -)--7 -3 7 , concerning the ,,property located at ® ijc'-r JJ,,y �-`� y ©`��+J meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There.are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : i I_ DATE: / i• LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j:ccrt w - . . �5. n G v 1 Y� f tt_ � @iGD ooM u0 GAtZ5AGE G¢a;�oEcz. �� 1 C HyE_ -C AvC FLow =1330 �.50•/3��497G:P. o `� UsE- 1006 GAL-. V. 1 o15PoSAL. PIT J55 1000 GAL• 6%pr WALL 150 5.� X �0 BOTTOM AREAL . l�0 5 F' � �'� q'1. 0 o } e 5F x 1� 0 ✓� v y P. �. -to-rA>... o�.StGN • �-25 G• n G � 330G -�oTAt- �AII.`( FL,Ovf = .P� ON) ('W (r <ax'Q odD PER.GOLATIoN RA'TE � I'�IN ZMIN OR.LGSS .I4, c 9 ^ V e f -57 t / Al AN Y E r 147, S 06 . 11 ��►acv iris �• 7 b 9 ToP FNU -too. 'i'6��T �J •>y�Y Mr (SAL. x .� INS. s6PTlG INS. M GAL. r�i(� i p LEAG11 INK INV. PIT L �G,y 3A rYL 1' D vJA sVAc o ' q 6TuNG � O CG62TIr-IGo PLOT PLp IenPRUFILG LoCA-TIoN tr' , No 5CP.LE7� - 1u- r�ATE• *�Z EF 6 R 2E N G E 1 G E Q-T AT -f N �C �vI.,O SNo WO Ht..p r GoMPt-Y5 YJIT2EMENYp of ZN5 a L. 1.J.p_S..ET�AGK R.6 Q v Ip-( WN bbF 8� tCA N6 GLooND LOGTD WITNIJ T D PISL.o)I.vINc�Q"" I Q�►J BQAc�Yc�TC E2Ze�NDYE IN�EC. LTL Z RLS61,5 t r_—QE6'D LAN D S u ZY r9l' n 1ve-YzA O� OSTEi.V1LL- -rN15 PLNN 15 NorT ►J TR- M -t.NE or5E5 s TuoUO APPt_1GA �IoHN QuE I 5 11 6N � 1: e n> EW^JOE L. -r V EIN N'T• : TOWN OF BARNSTABLE LOCATION '6 D SEWAGE # �— VILLAGE ��- • r ASSESSOR'S MAP & LOT 0 a7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 p0 LEACHING FACILITY: (type) i L&I (size) m NO.OF BEDROOMS BUILDER OR OWNER PERh4ITDATE: L`'J--7 - y COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Z - z� Q N®.-�L���----•• �` .3 •` Fps............................. THE COMMONWEALTH OF MASSACHUSETTS ( �"J - BOARD �` sCC—I E�c�A TH ........................•. Appliratinn for Disposal Wo rks C� strurtion rrmi# Application is//hereby made for a P rmit to Construct ( lepair of an Individual Sewage Disposal Systemat: / �.......................� .._....... - .............. �j _ }`' �� Location Ad I- ,� /.. J .. Lot ... --•- - Ow r �/ " ' . �----•.Address Installer Address d Type of Building Size Lot.• _ -Sq. feet U Dwelling—No. of Bedrooms________________________________ _____Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—Type of Building No. of persons............................ Showers yP g -•-----••-----------------•- P ( ) — Cafeteria ( ) Otherfixtu s -----------•----••----•----------------------------------------------•-- W Design Flow.................. ... ...... gallons per person per day. Total daily flow--------- ._ ...............gallons. ------------ WSeptic Tank—Liquid capacit� gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width_ ................. Total Length..__.j. ........... Total,leaching area.....- ........ sq. ft. Seepage Pit No...../-------------- Diameter......--------- Depth below inlet-.X?._............ Total leaching area�4 sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a 14 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........................ }4 .._._._ __ ___________ ___________4__ _ Description of Soil ¢ -, L. _.. ----- - - ------ ---- 4� ---------•-•----- ------•------ x ------------------- ----------------- -----------------------------------------------------•--.----------- U Nature of Repairs or Alterations—Answer when applicable.................................................•_..__.._._._.__._._._._.._.__.._.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance w' h the provisions of iI`IU 5 of the State Sanitary Code—TA undersigned further agrees not to place the yste in operation until a Certificate of Compliance has b Od4/the board of health. igne .•.. •--- -- - =---•---•••-•-•-•----•-------------•--•---• --•-•-•• ---_....... Da Z/ ApplicationApproved By- ----- •-• -•-----•-•-----••---•••-------•---•--•--•••.....---••..................•--------•- ..... .. --• --------------- Date Application Disapproved f th following reasons:................................................................................................................ ................................................. •••••-•--•----...--•--------••....._.._.._...---------._...--•-•----------•-------•-••-------•----•••............................ --•••......... Date PermitNo................................................... ® Date THE COMMONWEALTH OF MASSACHUSETTS BOA RD.. fF H-ENc .T. H OFd :-.-.-. e- . ............................................... Appliration for Disposal Works T, Witrnr#iun ramit Application is hereby made for a Permit to Construct ( or Repair `( ) an Individual Sewage Disposal System a art./ / �•^�A ._.�4�O �, `���f'� .. .orA Lddotr eN sso .. ............... ......._..... I Location Ad/^ :• .....--•---••---._.... � ' . ............ tr,'... ? .... Installe ......................Address Type of Building Size Lot.: ` •1 ..Sq. feet Dwelling—No. of Bedrooms._.____.._ ............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons_- ......................... Showers ( ) — Cafeteria ( ) dOther fixtures •---•-•••----------------------•--•-----•--•-••••---•-.__._--•-•-•--•------•••--••----- Design Flow.................Z:_____________________gallons per person per day. Total daily flow__.._._. .:__._____.._._____gallons. Septic Tank—Liquid capacit 3.. _ gallons . Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length..... ............ Total leaching area_--_y_�.. ...sq. ft. Seepage Pit No____ ______ _____ Diameter..... Depth below inlet__ ....___.__.. Total leaching area_;.!- t___.....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__________________.____. (Zq Test Pit No. 2................minutes per inch Depth of Test Pit...........:........ Depth to ground p water........................ i _....•------•• --•-----•-------------•------------.._..----..._......•------•-•--_•---- Description of Soil _._ .r '�,�e�a._ ._ �! I°- - (xj r s U Nature of Repairs or Alterations—Answer when applicable------------------------------ .................................. ----------------------------------- Agreement The undersigned agrees to;install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of,:the State Sanitary Code— undersigned further agrees not to place the yste 'in operation until a Certificate,of Compliance has b ens e the board of health.. ned. ykal . '.'_ , r J ___-. Dat Application Approved BY �.. ---•---------- ............... _ __---------•--- Date Application Disapproved f�, th •following reasons:--------------•..•.-----------••------------------..--..------•-------------•---------------------•--•-••-•••--- -----------------------------------------------------•-------------------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 4)F HE LT "!. ..........OF........ .�!t'i /dJ•.......................................................... �rr�ifirtt#r oaf �nnt�li�nrle � � , THIS IS TO CERTI That the Ir lyvidua/Sews ge Disposal System constructed ( or Repaired b �; iG'� .Cad �'� Y ------••-•• -•-••--- ------•----•------- .� .. has been installed in accordance with the provisions of TIT. 5 0 T e State Sanitary Code/.aes in the application for Disposal Works Construction Permit No.____ "�_ a_____.___. dated_--.-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................./.._', .'e Inspector..._._ .__ ' THE COMMONWEALTH OF MASSACHUSETTS BOARD jOF HE LTf ��-............... ......No FEE.__.....-----...... Disvosat , nrkv Ton-W ion rrntit .. � ✓ A `�` Permission is reby granted......... + ..._-'- A--- x w -•-------•-•-•---•.__••-•..._.__._••------•----•- to Construct Y or.Re air ( a an jn Kidual Sewag7 Disposal Syst6h ,-/ at No.._••---•-------- t x".., !;.....k t; f -_'_-.. !..!....... . ........ r u ------- . / street as shown on the application for Disposal Works Construction Permit No.__:71 //.....-_ Dated.......................................... / ------•--.... F --••---------•-----------•--•--••-••----•-...----••--•----•---•---- ff _ Board of Health DATE_ f FORM 1255 A. M. SULKIN, INC., BOSTON 5iQGL.G- FAMIL°! - -3 BEO'RnOM LY F I Ow I I o x 3 = 3 o G.P D• bA I C H Q1.E A v� �EPT1G TP�K = 33oxk,5o'/• = A97G.P. R •� „ � � � U51✓ 1 000{ GAL. D15PoSAL PIT v5E 1 v o0 (SAL. 51 DSWALL ActCA a 1 5o S.c; " 15o 5.F X 2.•5 c 3?5 G.P• o c�(, to BOTTOM p2EAt . �O 5•F._ ! 5o S.F �� i 'TcTA 1.. D E516N - 4Z 5 G.P 0' -TcTA%. DAII.o( FLolr�( = 33oG.Po Luc, q�1v G�, �- PE2Go�ATIoN RA?Et I'��N 2MIN O�LESS Ol � qe �o•d� .. M f OF l iia 1 too e G•S-2 o�P 4� N Y E " c a nN 19:i:34 4a Cill , ;In. tSlQU Tr +S' /1`/ TOP FUU T0�>T =100.0 WOLF P_ 332 Z nmr loon IWV. ugSolL BS` Cn�. .� Z IOoo INV. u 1G� TANK GM.. 966 0 LPIT INV. INV. WIT" I(-;.L l I I'�3/�1•I Vi l� WASK6D Y 4 6TuN6 S 5 f GE2TIFIGD PLOT PLAW o PRUFILr= LoG4zlotii e!:!�)Tb AA �2. �.0 NO�. SCAI.E'�_ 'ScAI•E'1 It1= w;�'�ATE: �• (J � �•1 �tb W13f27L REFE2ENC.E GE Ro1J GoMPL*{5 W�N N S I cELIN r-- - A W D S 6T 5o►C K R.6 Q V I R.is M E N'f� O F -T N G- :I -( >v N O 1,3C 'T- PUa1J Qor-< z6o Loop. ED •WITNIIJ TN6 GLOOp PLalt�l i dA"T ` C gAxTE2e AJ`(E INC. R.EG I S�r--a.r-v'I.AN D S u ev EYoe' ?uls PLAN 15 Nam' anSr..D c)d osT-EevI�L� •;MASS• lu5-rRvtAeW-r ISv9-Vey J� 'T ►AS DV-F5E'T5 5uouZ) �pHN V IJE�/ No`T-43� v5EDTo DE"TE.W^ICE �•4. uINES APPLICA►-IT �a1►� G�C-. FAMILY - •3 BEDROOM ►.10 GAQOAGE G21: DEtZ ;=LOW z Ito 3 = 3306-Po �� 1CFIt�;L �UL f)EPT1G u51c 1000' 6AL. j� ��J,FJJ D15po5AL PIT u5E 1000 GAL. 5%prLWA1.L AQ.614. = 15015.111 50T rOM AREA r .. � U 5 o S.F x I• o 5 b•P fl• ,�� f^ ��. .ToTAI- oESIGN = .4z5 G.RD. ' -ToTA<_ DA 1 t-.( F1-oV, = 33o G.PP r CCIac 60 OF (r PE2COLATION RATEt I'1IN 2MiN o�LE55 Q°I 'O y , , `J� 91� �- 41 `� 34 J At AN�o N Y E y �' 193 .. v r sF 14 7 o6 O=1fTF ��. I �;, .�Ifrn • TOP FNU = 100.0 -rs'�-r P- 33 Z Z -,,y C Y,.. �^� � I�• 17,0 /7 r 10OU L 1) ST. INJ. C, 56PT+G —Z Joao t►.IV. L3uK �G� TANK GAL. LEAcu PIT INV. INV. wlTu `l� L /G y 3A9'I/L (, WASNr,D �+ Q 6TvNCr S � o G C>= RTtt=1CD PLc>T PLAtJ PRUFILL _ L04A-T101.1 �Z �U 1,10 SCAL-EE2, 11U- tib wig P ►-A rJ R E F E 2E►� GE 1 CE RT11=Y GNAT 'fNE GG UC ��JI,�O 'Sub wN `{�,RFsOh.l GO/v`Pl...`(5 y,/ITN 'THE S 1 D�t_It`1 � A .D _S ET 5Ar,K R.6 Q v 12 E M E G '�" I Ca ►.I -ro w N -o - ,ED --S I_OCp. ED WITNI►JD AT Tub G�-ooD PL AII-I t 6AxTEQ.e tJ`{E INC. RLEGIS-t D Su2vE�(oe' -T►a►S PL&N 15 KJU7 C3nSr_D o►d ET uou C7sTE2.VILLF-_ - MASS. 1145TRUMENT -,v2VEY -TNE 0 S 5 S LD NoT Ca u550To pE7EFj1 \IQV_- L.oT L 1 F E--_5 APP I 30HKi D G•.Alic / PERMIT T NO LOCATION / SEWAGE E I dl L AG E INSTA LLER'S 41AME & ADDRESS 8 U I L D E R OR WNER � • e� ►1 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1 41 ' I rt-A2