HomeMy WebLinkAbout0064 BLUEBERRY HILL ROAD - Health 64 Blueberry Hill Road,Hyannis
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_- = T CO I-fO\`WEALTH OF MASSACHUSETTS
e� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENv1RONMENTAL PROTECTION
- 01\E R'I\TER STREET, BOSTO\ _`,LA 0210E (617) 292-5500
TRUDY CORE
8 Secretary
ARGEO PALL CELLUCCI DAB TRUHS
Governor ' sinner
t
�(f, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A
j — 'S l PART A
_,�/,�` CERTIFICATION y � e��
Property Address:l� � `"' �'�"`" r *`1 v Name of Owner_j A �p.O� O
lift
\k` V*V.'V4t.-)Address of Owner: `fig .�99
Date of Inspection: !YG' �t�' 9
Name of Inspector:(Please Print)! [ c4 tt e_1 _t I �EC��G Q
1 am a DEP approved/system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: 1q&Q , A'C _Ek tn r.._ A..s 1� +r-& I
Mailing Address:-? 2{ 2 7?,�?4• /-/ </le EiE lyA" 2-C4-c/ T' t
Telephone Number: Zo
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed•based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
XPasses
_ Conditionally Passes
Needs Further E-alIlin By the Local Approving Authority
Fai s
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to tfte
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
i� Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
p CERTIFICATION (continued)
'roperty Address:
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, of D:
A.`SYSTEM PASSES:
JC I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
I�
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determ/thetem is failin to ro c to t the
9 Ppublic health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH .303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a s t marsh.
i
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC TER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system AS)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 soil absorption syste and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption systf and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption sysem and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water anal is for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distanc (approximation not valid).
3) OTHER
f.,
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 1 .303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be ecessary to correct the failure..
Yes No ,
Backup of sewage into facility-or system component due to an overloaded or clogged S S or cesspool.
Discharge or'ponding of effluent to the surface of the ground or surface waters due an overloaded or clogged SAS or
cesspool.
_ Static liquid level in the distribution box above outlet invert due to an overloade or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is l/es han 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged r obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is belo . the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface ater supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a publi well.
Any portion of a cesspool or privy is within 50 feet of a pri to water supply well.
Any portion of a cesspool or privy is less than 100 feet t greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has bee analyzed to be acceptable, attach copy of well water analysis for
,coliform bacteria, volatile organic compounds, ammo is nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in additio o the criteria above:
The system serves a facility with a design flow of 1 ,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because on or more of the following conditions exist:
Yes No
the system is within 400 feet of as urface,drinking water supply
the system is within 200 feet �, a tributary to a surface drinking water supply
the system is located in a n'rogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such syste , shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further info,mation.
F
revised 9/2/98 Page 4of11
d%
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: V4 utbcc Vt1 t(
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N;A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions depth of liquid, depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b)I
The facility owner (and occupants,if different from owner) were provided with information on the proper.maintanaaca-0f
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address:
Owner: t r
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d.'bedroom.
Number of bedrooms(design):®, Number of bedrooms (actual;:
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no): 1,3
Laundry(separate system) as or no If yes, separate inspection required
Laundry system inspected ye or no)
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage(gpd):
Sump Pump(yes or nol:_�
Last date of occupancy:—(y"C"r�40T
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of'nformat'on:
System pumped as part of inspection: (yes r no)_fkD
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pri vy
Shared system (yes.or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)AV
revised 9/2/96 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_ other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:
(locate on site pl n)
Depth below grader
Material of construction:1concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Wage confirmed by Certificate of Compliance—(Yes/No)
Dimensions: J�W�
Sludge depth: )It s(
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness: sA
Distance from top of scum to top of outlet tee or baffle:-
Distance from bottom of scum to bottom of out et tee or baffler
How dimensions were determined:
'omments:
(recommendation for pumping, condition of i let and outlet tees or baffles, depth of liquid level in relation to outle invert, tr tural' egrity,
evidence of leakage, etc.) i u A s
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
y®� SYSTEM INFORMATION (continued)
'roperty Address:
Owner: ��/rv�✓
Date of Inspection:
TIGHT OR HOLDING TANK::(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:196
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: _
(note if lev I and istrib ti ' equ I, evidence of lids ryover, eviden e f I kage into or out of box, tc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working in order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,•condition of pumps and appurtenances,etc.)
I
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4operty Address: � Not tu
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excav ion not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number: x,'
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of s il, signs of hydraulic failure leve of png, amp oil, condition of veg tation, etc.) e dr
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate hte plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: (pLlIvc �
)wner: Illy
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
�y
4 � �
Ak -33 7BI
b7, 20
31
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: (01� 15E'W�
Owner:
Date of Inspection:
NRCS Report name l Z
Soil Type_
Typical depth to groundwater _
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope PO
Surface water 00
• Check Cellar
Shallow wells tAOr
i
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
AkObserved Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
t(#/V(071c VV5
revised 9/2/98 Page 11of11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL 3
DEPARTMENT OF ENVIRONMENTAL ON
ONE WINTER STREET, BOSTON MA 02108 (617) 2 00
WUJ.IAM F.WELD Z UDY CORE
Governor r! 8 19 Secretary
ARGEO PAUL CELLUCCI Ti D B. STRUHS
Lt. Governor Commissioner
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: G%k ��uG9G¢q�1 '\ I Address of Owner: �1�d,
Date of Inspection: a\..��-� C�C� v%S (If different)
Name of Inspector: H
Company Name, Address and�Telep ne�umer:
`b
CERTIFICATION 12STATEMENTy- "'& 9 \ �.�,
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signatur Date: a��y\�`
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:
Check A B Cr or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 11/03/95)
M
IL. PriotlKj on Rrcvded Pam-r
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
.f
Property Address
X,
elo
MOwner^
Dat *o" Insfp .Y,%n fJ Bf!SYSTEM CONDITIONALLY, PASSES (continued)
r breakout or high static water level observed in the distribution box is du o broken or obstructed
�i=''Sewage backup'�o
�. pipe(s) or due'to a broken, settled or uneven distribution box. The system will pass inspe ion if(with approval of the
tl - Board of Health):
broken pipe(s) are replaced
✓ obstruction is removes
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or o structed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES T AT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY A THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering v etated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH ( D PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT ROTECTs THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil abso tion system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil a sorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil sorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and so i absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water anysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facil' and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
3) OTHER
(revised 11/03/95) 2
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as fined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to d termine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloade or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surfac waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or availa le volume is less than 1/2 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 Soil Absorption System, cesspool privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 f t of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a ne I of a public well.
Any portion of a cesspool or privy is within 0 feet of a private water supply well.
Any portion of a cesspool or privy is less han 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If th well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic co ounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large cyst ms in addition to the criteria above:
The system serves a facility with a de gn flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the em,ronment because one or more of the following conditions exist:
the system is within 40 feet of a surface drinking water supply
the system is within 00 feet of a tributary to a surface drinking water supply
the system is locat d in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water sup y well)
The owner or operator of any suc system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 d 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
1
,r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: !oy g\ems y \\
Owner:
Date of Inspection:
Check if the following have been done:
APumping information was requested of the owner, occupant, and Board of Health.
4None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
I during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
1 built plans have been obtained and examined. Note if they are not available with N/A. /
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption 'System on the site has been determined based on existing information,or
approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper Xofb-
Surface Surface Disposal System.
(revised 11/03/95) 4
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property(G
Address:
Owner: QNpv<-,
Date of Inspection:
1 FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current residents: OS
Garbage grinder(yes or no):_k-,pi
Laundry connected to system (yes or no):_c,z,S
Seasonal use (yes or no):w
Water meter readings, if available:T�
Last date of occupancy:
COMMERCIAUI NDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�S�Te.v... •.e rda Pu,�...,,p�..+ 'System pumped as part of inspection: (yes or no)_�LO
If yes, volume pumped: Gallons
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: u�
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) $
SUBSURFACE SE\WA.GE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: C,P.a ,e—se—
Date of Inspection:
SEPTIC TANK: -4
(locate on site plan)
Depth below grade: %2�
Material of construction: �)1 concrete _metal _FRP _other(explain)
Dimensions: \6cx3 s t\
Sludge depth•-A%
Distance from top of sludge to bottom of outlet tee or baffle: �Z►�
Scum thickness: 4 t'
Distance from top of scum to top of outlet tee or baffle: to
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condi�ion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) +rs. GW%W".A D%-hyftAQ#Q4-- •►�-em--t� ae 1'vVQ -'A*QTLJ-
1
GREASE TRAP: 0
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —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:
Comments:
(recommendation for pumping, condition of inlet and cutlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION (continued)
Property Address: 69 Blue
Owner: C�Na✓��_
Date of Inspection:
TIGHT OR HOLDING TANK:_u0
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: Gallons
Design flow: Gallons/day
Alarm level:
Comments:
(condition of.inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_MGS
(locate on site plan)
Depth of liquid level above outlet invert: VA
Comments: TT
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, etc.)
IL
PUMP CHAMBER:_NO
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property//Address: 4 y $fVZ&V'z'1 t
Owner: -eyw✓.nt,
Date of Inspection: .21 L y
SOIL ABSORPTION SYSTEM (SAS): 5
(locate on site plan, if possible; excav ion not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_,�Grc.(,
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failwe, I el of ponding, condition of vegetation,etc,)
ris -
CESSPOOLS: Nv
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: Ca�L/CW— I
Date of Inspection: 2A b�
`1Z
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
bL\
y
DEPTH TO GROUNDWATER
Depth to groundwater: ' 2.6 feet
method of determination or approximation: V. LSL)9,'J
(revised 11/03/95) 9
` TOWN OF BARNSTABLE
LOCATION tD'A QA ut'Q3Z`2uL..t 4 \\ v-cA SEWAGE #
VILLAGE "VnrtowtS ASSESSOR'S MAP & LOT a
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 obO E5 PA S
LEACHING FACILITY: (type)217 (size) \Ooo!21.A i
NO.OF BEDROOMS 3
BUILDER OR OWNER ��-sa
PER.MITDA-TE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the y �O 1 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) tO Ifs Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) r3 Feet
Furnished by A-2'-e.AC AD
tT
� 1�4
1
Z
�L- 3W bL—a6'
36' V63— a,e'
lot\.`— -5c, Ry— 33
"' $ jTOWN OF BARNSTABLE
LOCATION 6y a-Logl3"Ok lf.lf (?L SEWAGE #
VILLAGE fHYAo ty,�,S ASSESSOR'S MAP 6 LOV41 .-4t7I
INSTALLER'S NAME & PHONE NO. "�U-6�A %t4 � 036
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) kN— (size) 01v�
NO. OF BEDROOMS _2 PRIVATE WELL (R:P:UB:LIC WATER
BUILDER OR WNE ,twk �
DATE PERMIT ISSUED: A %P 9 i
DATE COMPLIANCE ISSUED• �'A
VARIANCE GRANTED: Yes No
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9
No.. -...� Fxs... .....:"...�...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diripwial Wi orkai Cnnnitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
...� ..........E Mqs:4f-i�+
....tia� ...... ------------- ---•-•---•-..............................................................
-i\ddress or Lot No:
---------------- ......
ow'Ier Address
Iustaller Address
UType of Building Size Lot............................Sq. feet
,., Dwelling—No. of Bedrooms.-------------------------------------- ....Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons......................... Showers ( ) — Cafeteria ( )
Qt Other fixtures ----- ------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic 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 ( )
Percolation Test Results Performed by-------- -----•----.-----------------•------------------------------------ Date........................................
a
Test Pit No. I................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........................
9 ---------------------------------------------------------------------------------------•------------.........................................................
0 Description of Soil------ ----•---...--- - .......................
------•..............y . ....5�
x
W
UN re o Repairs or Alterations—Answer when applicable.___-_.1 `1'tL -_.......ifJ -Zi.......... o�a ...._..5'�l
le V7 _ w _..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compl' n�s beeY- Z
ed b the board of health.
Signed .... ............G-� -.. -------------....---......------------------------.----- .........aR......H rb... ......Y
Dare
Application Approved By ............... ....� ( .,� ................................................................ ............ .. .�..,�. /
..r �-------...... Duce
Application Disapproved for the following reasons: . .................... . . ..... . . ........ .........................................
................ .................... ...... ... ......................... ..... ................... -- ........................................ ........................................
Permit No. . ?�....... .V_ ..
... Issued ........................................................D�e
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( f�
by ......... ........e0`N.& .. ......0-0.......... ........... ............ .......----------------------...---..---.----------------------------------
" Insr,Jlcr
at ........( ..... -G.....................rwc-Yz�........�_`.. c�.� .................... .Ky,PrN.! 5------------------- ----......-------------------------------
has been(installed in accordance with the provisions of TITI.E 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -----(:�'.._....._../-�/ dated ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C�NSTR(JEAr-A-S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........�..` ""e ... .... . ......_........ ...._ Inspector _.,6-�+...�..`..__.._..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CCpp TOWN OF BARNSTABLE
Dispnoal Worki5 Tuntrnrtion "Vern fit
Permission is hereby granted•--�-NA)) Lzl%........P.0 r....-•- -------- ................................................
to Construct ( ) or Repair ((<p an Individual Sewa e Disposal System
at No......� ......... L..►J_�._ f� \ 4 t�......... 0� .... t-t4
Street
as shown on the application for Disposal Works Construction Permit NoJ- f,/-"-3__ Dated----------
�oard of Health
DATEj" --•-•-----••---•--••--••---•----....
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
r...w++-. +_ �'_ f ....C"'tug..�'.'."4a.......:�.e.++Craw++.....+1".--:.-a.....--.rd:.+u'.�.""'C-....r:.J''r.,,Is-'w.:a..yJhyr+w.....y�:1L.�...rS/..i+r�Ja�v,Cr:`al.,:.�i M�"'+hY•`�''��
No...��-._._/..y.3 F�S..�.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
i Allp iratinit fur Di ipwml Works Tvastrnr#inn Permit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at
... ...------► ...... t_-...---14? -------------- - �W_0_�s----------------------.....-----..---------------.-.---------....
-,Locatcon-Address or Lot No.
......... ���.�c _ � -------------------------------------------------------••--
owner ,+ Address
a ff --------eQ -------- .... . ........ r - .--t`--........X-�4��v'�..--------
Installer Address
Q, Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) Cafeteria ( )
a' Other fixtures ...............................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
tx Septic Tank—Liquid capacity............gallons Length---------------- Width................. Diameter................ Depth................
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........................................
a
Test Pit No. I.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Lit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil_.....(-?._.._.._ v Z—
x -------•--
U .. ......•-•••••••--•---•...••-------••...............•----•------.........•-•...--••-•------•-•--•---------•---•------------•••----•---------••--•-----•-------••--•••------••---••-•.......-•--•-•...••--
W ................................:.......................................................................................................................................................................
U Na ure of Repairs-or Alterations—Answer when applicable.__.-.�_W J'�...4 __._.....IlN.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
! the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
a; system in operation until a Certificate of Compliance has been issue�d'by.,thehboard of health.
Signed ................... .. _ �
... .... i. ...(.9.y
Dace
Application Approved B
pp pp y ................. �_reafons:
`R` ---------... �'; e. .-d,..1c'' 4Application Disapproved for the fol ------------------------------------------------------------ --------- ............--..............................--........
..................._....-...........-.....-...\.................-.........--.....-----...-..._..............--------...-............................,*..--.....-.-...-.------._-----------._------. ..............--Date ------.....--..
Permit No. — /..--....-.. ........... Issued . .. ........ ........
. y
Dace
(- (� ui i
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600
ai SENDER: I also wish to receive the
v ■Complete items 1 and/or 2 for additional services. following services(for an
0 ■Complete items 3,4a,and 4b.
N ■Print your name and address on the reverse of this form so that we can return this extra fee):
a card to you. v
d ■Attach this form to the front of the mailpiece,or on the back if space does not 1.❑ Addressee's Address
■Write permft"Return Receipt Requested"on the mailpiece below the article number. 2.❑ Restricted Delivery N
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PIi`PS FormMl1.,`,December,`1994 i i I H i i i€r to2595-98-B-o229 Domestic Return Receipt
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Down C* Engineering, Inc.
9M "n St. — Suite C
yarn,xxAh Port, MA 02675
fifill 11 fill 1 111 111111 11 flikil Illifiliffil Ild
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ai SENDER: I also wish to receive the
o •Complete items 1 and/or 2 for additional services. f0110W1n services for an
rn ■Complete items 3,4a,and 4b. g
d ■Print your name and address on the reverse of this form so that we can return this extra fee):
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w Pb Form 3811,Dece ber 1994 162595-98-13-0229 Domestic Return Receipt
UNITED STATES POSTAL SERVICfma. First-Class Mail
Postage&Fees Paid
C � ermit
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®Print your am, d4re6"s�and ZIP C .deei i
Doran Cape Engineering, Inc.
939 NSWn St. — Su�o26�5
Ya�rmotAh Port, W
P.�C-Elsa i
a SENDER: I also wish to receive the
■Complete items 1 and/or 2 for additional services.y following services(for an e Complete items 3,4a,and 4b.
at ■Print your name and address on the reverse of this form so that w6 can return this extra fee):
card to you. ai
m ■Attach this form to the front of the mailpiece,or on the back if space does not 1.❑ Addressee's Address 2
C ■CU Write at"Return Receipt Requested"on the mailpiece below the article number. 2.❑ Restricted Delivery N
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UNITED STATES POSTAL SERVIQBm+ First-Class M811
PSP &Fees Paid i
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®Print your arre. ?ddresss, and ZIF�5Z az Is Qx>a
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Down Cape EnginQehng, Im.
gap gain St. — Suite C
Yacrmcoh Port, mA o2675
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a� ■Print your name and address on the reverse of this form so that we can return this extra fee):
in card to you. u
ry ■Attach this form to the front of the mailpiece,or on the back if space does not 1.El Addressee's Address
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2 PS Form 3811,December 1994 102595-98-13-0229 Domestic Return Receipt
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UNITED STATES POSTAL SERVICE First-Class MailPostage&Fees Paid
Print your re, -;a
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Down Cape Engineering, Inc.
939 main St. — Suits C
Yarmouth Port, MA 02675
L'c�-sore � •.,
' SENDER: I also wish to receive the a.
:o ■Complete items 1 and/or 2 for additional services.
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LISPS I)
Permit No.G-10
o Print your name, address, and ZIP Code in this box
N Down Cad ��clr✓es Irt,,.
339 main 5t. — Suite C',
yar4XXth Port RAP► 02675
1 �
SENDER: I also wish to receive the
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rn ■Complete items 3,4a,and 4b.
N ■Print your name and address on the reverse of this form so that we can return this extra fee):
card to you.
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UNITED STATES POSTAL SERVICE First-Class Mail
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Dom Cape Engineering, Inc.
939 MWn St. — Suite C
Yarmouth Port, MA 02675
• �o.�-so r. �csci•-
ai SENDER: I also wish to receive the
;o ■Complete items 1 and/or 2 for additional services. following services(for an
(A ■Complete items 3,4a,and 4b.
a) a Print your name and address on the reverse of this form so that we can return this extra fee): I
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m ■Attach this form to the front of the mailpiece,or on the back if space does not 1.El Addressee's Address
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y PS Fog 3811,December 1994 102595-98-B-0229 Domestic Return Receipt
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UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
®Print your name, address, and ZIP Code in this box
Down Cape Engineering, Inc.
939 Main St. -- Suitt C
Yarmouth Port, MA 02675
fii,I��si�i�H��i,tfi,i�i,li���i
1
ai SENDER: I also wish to receive the
o ■Complete items 1 and/or 2 for additional services. following services(for an
w ■Complete items 3,4a,and 4b:
a) ■Print your name and address-on the reverse of this form.so that we can return.this extra fee):
card to you.
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Down Cape Engineering, Inc.
gag kUn St. — Suite C
Yarmwth Port, MA 02675 -
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n card to you. �
m ■Attach this form to the front of the mailpiece,or on the back if space does not 1.ElAddressee's-Address
Y
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ri e■The Return Receipt will show to whom the article was delivered and the date
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T X
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UNITED STATES POSTAL SERVICE First-Class Mail
a&Fees Paid
USPS
Permit No.G-10
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Down Cape Engineering, Inc.
939 Main St. — Suite C
Yarmouth Port, MA 02675
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UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
® Print your name, address, and ZIP Code in this box
Down Cape Engineering, Inc.
939 Main St. — Suite C
Yarmouth Port, AAA 02675
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939 main street rt 6a ; `±
yarmouth port
mass 02675 I
down cape engineering, MC.
civil engineers&land surveyors
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tel.(508)362-4541
939 main street rt 6a fax(508)362-9880
yarmouth port
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2675 /Own Cope en jineefing
civil engineers& land surveyors
structural design - r
Arne H.Ojala P.E., P.L.S.
Timothy H.Covell,P.L.S.
Dam el A?Ojala, P.L.S.
land court
surveys December.,22 1999 W t-
Tim Pearson
site planning Markwood Corporation
110 Breed's Hill Road
Hyannis, MA 02601
sewage system
designs Re: Lot 54 Gooseberry Lane, Marstons Mills
Dear Mr. Pearson:
inspections
A public hearing has been scheduled for the Barnstable Board of
Health to take action on your request for variances from a Title 5
permits regulation. The variance requested is as follows:
Title 5 15.214(1) Nitrogen Loading Limitations: To allow construction
of a 2 bedroom dwelling on a 10,575 sf lot (to be allowed under
15:005..,;-"Transition Rules".)
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Said hearing will be held in the Hearing Room of the Barnstable'_Town
office, 367 Main Street, Hyannis, MA, probably in January; 2000.
Please check with the Health Department to confirm exact date
time.
1
:r Sincerely,
Sarah B. Ojala
Down Cape Engineering, Inc.
cc: Abutters
file
Barnstable Board of Health