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HomeMy WebLinkAbout0619 OLD STRAWBERRY HILL ROAD - Health 619. 01d Strawberry Dill Road r- ',} Hyanni M s - . F 1 A = 273 -008 F u e TOWN OF BARNSTABLE LL LOCATION OLD SM9t,( 669IN 41 L�,'SEWAGE # 2 " ' .y VILLAGE C�X ASSESSOR'S MAP & LOTr77J 16OR INSTALLER'S NAME&PHONE NO. S ) � SEPTIC TANK CAPACITY P: U LEACHING FACILITY: (type) O!%1.,1.77��'II?�S (size) L� l'X ��►��p ' NO. OF BEDROOMS 0 as+f-Ld7 00 BUILDER OR OWNER Q9A I PJ e(md / PERMITDATE:� � D& COMPLIANCE DATE: I 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_DaO exi SLJ TOWN OF BARNSTABLE LOCATION Qq P1M (, i`QD SEWAGE # VILLAGE _ ` 4041VAI.S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.—AM l t t � SEPTIC TANK CAPACITY ISM LEACHING FACILITY: (type) I n F I10Vi TM �,,, ��y (size) _A i X IQ•/(O � NO.OF BEDROOMS r4s, ,Y tz e BUILDER OR OWNER 1)pfm l L1, 00A).D PERMITDATE: COMPLIANCE DATE:_1 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 I.eacl4ng facility) Feet Furnished by I n i q o - w s c o's VI\ " ` / •V�No. , t Fee .. THE COMMONWEALTH OF MASSACHUSPETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Miopooal opotem Conftruction Perron Application for a Permit to Construct( )Repair( )Upgrade(V(Abandon( ) El Complete System []Individual Components Location Address or Lot No. O er�'s Name NAs �TellNo. /� p /y�,Assessor's Map/Parcel � K D �tl1 r�G4 l-C/{� � MW 3 D Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel No. P� �lU ��y7gu? n28 ql S p Type of Building: j Dwelling No.of Bedrooms v Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 8, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date a —/ -0 o Number of sheets Revision Date Title Size of Septic Tank (7 Type of Description of Soils kDQA'�2tl� n$ t Nature of Repairs or Alterations(Answer when applicable) 04kZ &/S&f2e Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance a afore described on-site sewage disposal system in accordance with the provision tle 5 o the En ' onmenta Code d of to place the system in operation until a Certifi- cate of Compliance has b s and of alth. igned Date Application Approv by Date i Application Disapproved for the following reasons Permit No. 6 Date Issued No. I ._ ,`r Fee loo THE COMMONWEALTH OF MASSACHUSPETTS Entered in computer: �_ Yes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYicatton for Ztgozal dip.5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(/Abandon( ) ^O Complete System ❑Individual Components Location Address or Lot No. R/C4 ©161 I f�t rr �( Owner's Name,A ress and Tel.No. be r►' )�r7 r kd C r 'volt. Assessor's Map/Parcel f a -_ Installer's Name,Address,and Tei�. Designer's Name,Address and Tel.No. ra ell,e�? la er 90, �r Type of Building: Dwelling No.of Bedrooms 4o Lot Size. sq.ft. Garbage Grinder( ) Other Type of Building f' RP_S . No.of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow gallons per day. Calculated daily flow gallons. Plan Date n -/ -d Number of sheets Revision Date Title x Size of Septic Tank 57J b Type of S.A.S.( Description of Soil<< C t tBl ✓I li{�1 Li'Y7// .SCn 7 /�P� t�/� Nature of Repairs or Alterations(Answer when applicable) Aojf,/,l`�L.. &I�hlgr, &.SS/)o Date last inspected: ' Agreement: The undersigned agrees to ensure the construction and maintenance the afore described on-site sewage disposal system in accordance with the provisioZotle 5 o the En ironmental Code and not to place the system in operation untila Certifi- cate of Cbtnpliance hasben,isis lard of Health. Igned Date Application Approve. by Date Application Disapproved for the following reasons Permit No. & Date Issued 01 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance µ THIS IS TO CERTIFY, that the On-�ss to�Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by 1 �fIUY s at U / has bee, constructed in acc�°�jd-ance with the p ovisio s of Titlet5 and the or Dis osal System Construction Permit No.A��o'Vd dated �9 ! 1� Installer l�m L fl}� Q��!)VS r � lArA �/P1/Designer . 1 P ,0F_-hZ S The issuance of this permit shall not be cons ed as a guarantee that the system will ct' n as designed. Date Inspector No. � � ^-- 'L'l�� -------------------------Fee /0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS-` jBigogal *pgtem Congtruction-Vermit ,w. Permission is hereby granted to Cons c�)Edw",u )Repair( )U�j�,rade(AbandonSystem located at b/ ©i� N'/�� f 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 must be completed within three years of the date permit. Date: t � Approved yy Town of Zarngtable �;,�, Regulatory;Services 4, Thomas F , ilerDirector ,Mv! Pubhc Health DiVislon Thomas McKean,Director 200 Main 1.Street,Hyannis,Mk02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Cer;tifcation Form Date: D ' Sewage Permit# Assessor's Map\Parcel_3/ 3 Designer: k" Installer: 1 dh1 pK ft (L Address: Pdjb?C �� �•�Gin(W1C.rli1 Address: �(� D�( 7�� lX�(,S' On C? aq 0 pKM C'0aMD9n-Z 25 �as issued a permit to install a se tics ystem at ( � ��''�( � ,J P ( 9-0based on a design drawn by P (address) DAUtA M A Ud dated (designer)' I certify that the septic systemreferenced'above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e.greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic Stem)but in accordance with State&Local e ation Puri r visi or certified as-built by deq eq follow. DARI��(Installer's Signature) o C Ado 0. 1140 GISTS SgNITAR\P (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO-BARNSTABL UBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION:THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc Doc= 1s0,44s584 09-21-2006 9-23 BARNSTABLE LAND COURT REGISTRY DEED RESTRICTION WHEREAS, Daniel P Pond - Kristin R Pond of (owner's name) 619 Old Strawberry Hill Rd Centerville MA (address) is the owner of Home located (address) at 619 old Strawberry Hill Rd Centerville MA and being shown on a plan entitled °Subdivision of Land in Barnstable MA, Property of et al, duly recorded in Barnstable County Registry of Deeds. I.& Z3 Or on Land Court Plan Number 32849-A (sheet 2) WHEREAS, Daniel P Pond - Kristin R Pond as the owner of said home has (owners name) agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in my home on a pre-condition (� to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to \ granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, in ( agreement for the restriction on the number of 1� bedrooms and put on record with the Barnstable County Registry of Deeds by recording this document, 0 • 6 l 1 ✓,'THEREFORE ,Daniel P Pond- Kristin R Pond does hereby place the '�r's name) following restriction on above-referenced home in accordance with his -t' agreement with the Town of Barnstable Board of Health, which restriction shall run with the home and be binding upon all successors in title: 1. 619 Old Strawberry Hill Rd Centerville have existing house (address) upon the lot a house containing no more than Three (3) bedrooms. Daniel P Pond - Kristin R Pond agrees that this shall be permanent deed (owners name) restriction affecting located on MA, Or on Land Court Plan 32849-A (Sheet 2) For title of see the following deed: Book , Page . Or Land Court Certificate of Title Number 130791 Executed as a sealed instrument oZ 0 day of SAP* se)0,6 Until at a time when the homeowner is able to connect to town sewer service and remove home title fiv ptic system if so desired by owner. Then this deed restriction will be void an remo ed fro ec n s ' o returned to original form. Owner's signature p Owner's signature COMMONWEALTJH OF MASSACHUSETTS ss 20(�c Then personallij app6ared the above-named R known to me to be the person who executed the foregoing instrument and acknowledged II the same to be=� free act and deed, before me, Notary Public My commission expires: . „ r `�`�,':?1;=C r1!•7 x BARNSTABLE COUNTY (d VfNOTARY PUBLIC �d";:; ymt?� REGISTRY OF DEEDS '� A TRUE COPY,ATTEST ll Commonwaft Or Massach s tl' LE e 9 � My Commissiai Expires June 8,20M2 3 , 'JOHN F.MEADE,REGISTER +� f• Ole Cl iu "u. BARNSTABLiEGISTRY OF DEEDS GENERAL AFFIDAVIT 1. Commonwealth of Massachusetts County of 1�dt,n s4mbl a BEFORE ME,the undersigned Notary, [namP.nflYnlary before whom affidavit is..sworn],on this 9.45 [day of month]day of :50-1 rmonth],206,E ,personally appeared DA-AR k_ 0 000 (name of N iant],known to me to be a credible person and of lawful age,who being by me first duly sworn,on_ this or her]oath,deposes and says: The house has not changed in any way since I purchased it in 1993.No changes have been made to the structure or rooms added. [set fort ant's statement of facts) [signature of affiant/ Daniel P Pond [typed name of affiant/ 619 Old Strawberry Hill Rd CentervilleMa 02632 [address of affiant, line I] [address of affiant, line 2] Subscribed and§worn to before me,this q o ` [day of month]day of A-� [month],20 . [Notary Seal:J f [signature of Notary] �. c [typed name of Notary] InkMen Chitkara NOTARY PUBLIC NOTARY PUBLIC Commonwealth of Massachusetts -Ay Comm' on Expires June 8,2012 My commission expires: ,2} TOWN OF BARNSTABLE LOCATION (e q Qc� 7lr��l�p�.� .III'-�' SEWAGE # VILLAGE �'1 � ', ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.(f-,,,,., SEPTIC TANK CAPACITY -. c LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR F BLIC WATER BUILDER OR OWNER AP h )qa cAk ✓ ,! y � DATE PERMIT ISSUED: D - 0 h DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� � ���. ,� a 1- �� -.� ` ` �,, �? �- o � � � ® E � � ,n�4- � �' � � ��- �. , .. i R THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE 2 3^ate Appliratiou for Eliipntial Works Tomitrurtiurt ramit Application is hereby made for a Permit to Construct ( ) or Repair (C__)—gr- ndividual Sewage Disposal System at: .......... . ­N_.---_-�Z,a.... vw ............................ ............................................ ......................................... Location-Add ess or Lot No. .... �.�!�1..... .1.'.D wJ v Y.............. .....................G_ 4....----------------....-•--•------............... Owner Addre s ......... a (.. � 5.. ------- ..............................----------------- _�S- - ................... Installer Address dType of Building Size Lot----------------------------Sq. feet aDwelling—No. of Bedrooms....................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria 0.' Other fixtures -----••----•--• •-••--••------•--•......•-•••---- w Design Flow.._..._..�>_....................gallons per person per day. Total daily flow.-_-_emu... ..................gallons. GG Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No.-------------------- Width.................... Total Length_......._...i...... Total leaching area...................sq. ft.' Seepage Pit No....._------------- Diameter....k�._------ Depth below inlet.....:V.......•. Total leaching area....................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-___--_-_____-____._.--. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ •------------------------------------•--•--•-------•-----.....-•--•-----•------••---.........------............................_........................... 0 Description of Soil............................................................................................................................-............................................ x U w - - ---- ----- --..- - - U Nature of Repairs or Alterations—Answer.when applicable._- '� ________1 . .__. -' _c�._......_... 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 Com e has be n is he Noard of health. Si ed - / .��.�<.Q....... Date ApplicationApproved By .............. .. -- .------..............--------- .......-- .....14--�Z.... S........................................ Date Application Disapproved for the following reasons- ---------------------------------------------------------------------- ------------------ ...................................... -----------. --- ------------------------------------------------------------------------------------.................... ----------...--------------- --------------- ........................................ �/ Dace Permit No. �..� C,r�------------------------------------ Issued ------.. ��� —' ---- Date ............. v No._ Fps......���............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 2 7- Appliratinn for Disposal Works Tnnstrnr#inn jhrmit Application is hereby made for a Permit to Construct ( ) or Repair (4.,),ari'Individual Sewage Disposal System at: r ........... { �....... =�' -c�C----•-•--•--•--------------- -----••-----. Location-Address ( ( / or Lot No. ' ^— �'�- ��•s- � t.v C .�!!v...rF*�!.� ............. .7 -•---•--------------------- ---- ......... - -- '- Owner Address a ----------1. _. !�L?- ------------- Q�.o....... �: , �......_... --------------•,�_ 1 V=s :�.. Address �. �{^ Installer d Type of Building f Size Lot............................Sq. feet aDwelling—No. of Bedrooms.._..-_.�3_'--------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ;---•---•-----•----------•---•------•--•--•••-•-----•-.-----•-------••••----------•-•------------•--•-•-------------------------•••--...........-----• W Design Flow......... --------------------gallons per person per day. Total daily flow.... ��_v�.................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......N__g--------- Diameter...__ Depth below inlet...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ..a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................... •---•-•-------------------------------------------------•--•---••--=----•---.---------.-.--------•---------------------------------------------------------- tDescription of Soil.............................................................................................................................................................. x W - - -------------------------------------------------------------------------------------------- --------•-----••--------------------•----------••-----------•------------------•----------•...._.._...._. U Nature of Repairs or Alterations—Answer when applicable__- m.s _a 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 Compliance has been issued by the board of health. ,f Signed":'.d,.... ` - -- --- ................ ----- Dace Application Approved By .......................... "----------------------------- ------ ------- .......16 _Z.....f a . Application Disapproved for the following reasons- ---------------------------------------------------------------------•---------- ----------------------....------------............ ------------- ------------------------------------ -- ----------..... ---------------...----.............---------- .................................. -----...--------......._.....-�-Z------... ......................-- "" Dace Permit No. /�"y�7..... .......... Issued 1l) � Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�e>r#tftrate of 1011-0myliaur.e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b5 .. .. �....... � Installer at ............................tom �.. ............. �` .f �c-r�..�:.�� - ^4' - ./I------ .........................................-..................------..............---.. has been installed in accordance with the provisions of TIfLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .............. �------ dated ....../..-.2_--fL,a-..- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT gE CONSTRUE` AS A GUAR 'NNTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... `�� -1,�.� � Inspector ........ ........... ............................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /� TOWN OF BARNSTABLE No..... (✓... L... FEE...... ........ Disposal Works Tnnstrudinn "Prrnti# Permission is hereby granted--------•--• w= mac, r.71,--�...................................................••--....... to Construct ( ) or Repair ( man Individual Sewage Disposal System v� t t y J s r C;.1,_......•..... �. " •-•----•--••---•-................................. St eet as shown on the application for Disposal Works Construction Permit No.. /).�v Dated..__../0_,Z...... ........... DATE..... �Q ............................................... Board oV eaIth FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS ry — e V ASSESSORS MAP : 21 TEST HOLE LOGS NOTES: PARCEL: 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH $O 1 L EVALUATOR : 1). �ltegeK �S . CSC S PLAN, 1945 MASSACHUSETTS TITLE V & TOWN OF nAgASTAU FLOOD ZONE : N FI WITNESS : BOARD OF HEALTH REGULATIONS, S REFERENCE : V p'l'' tool q DATE: 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RATE: 4 M 10 1 uA SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO —* 'N� d INSTALLATION.' C�A'55 1 501 E. {,TAW, 0,? �P tr y` a C 9 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION Qt' TH- I fit~' ��.�� �r► TH"2 c.L . 7�ti ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE �jjtrl�peq �. �/ A `JAt D I 11. (_ >�3/:.....flit 12. .. 7 �2 f 4) ALL PIPING TO BE 4 SCHEDULE 40 @ 1/8. / FOOT (UNLESS ej Cjpr•1'1x> � ` �J ►J r'l ( �$� SPECIFIED OTHERWISE) LO (bZ��� ` 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE.USE OF A LOCATION . MAP LvA4NA o Lo�n,1 C ��� � `' /4 I �� /� GARBAGE DISPOSAL. i .��Ir �c�(I� 7► ' 'D 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) ►�l�E.(?�V NI1�l U,�v` I MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON j �� �� 2`� � c(��rl?' �2 ��� 2,5 � ���'17 ABASE OF 6"OF CRUSHED STONE. � Y4 / 2 �- `eX1%T7ij - . CC5apoo4�,S T�. t E pt l �17/. G 1 1 _.._.__._... rx�eA� �� �n � �►� tv I�-�1�0 i lllo C� r 2.� � R�►� w� .�r� >. �wec+nn. I-{u v5 : TU .-rktN K. SEPT I SYSTEM DESIGN _..P Co^)�<_T*G> To �6r 19-00 A .m-alze NO P�24 VAM WELLS w/r d 15' or Paap. L,eAf,*- t. FLOW ESTIMATE -'r2F_Mvw'tL to I b b w �"t prn►r Vu 1 l � ©r- FL; ta 69'' � BEDRCi0M3 AT 11p GAL/DAY/BEDROOM - `T 4D GAL/DAY II- . MOVe �fu, uN,3w7)i-w'e Sot k,S 5 F-r hl-vvNr_> iB3.92 FL. """ "'.' ------- (� SEPTIC TANK L6A04 rYl 7D �5L,: (96-Y5 69, 169 0 P C , LDT 23 144b GAL/DAY x 2 DAYS ° D GAL - VJ( "� �U i ('n^?�,•'. .._..... ....... • C�SSP -S "~ /iRE/i = 8�98 s - ''�.t USE I C) GALLON SEPT I C TANK +u( 1 OCz, �11wA/ e?r— 640t SOIL ABSORPTION SYSTEM (1SE '�Ouy .,h I f / / (� E'w,� r BENCH MARK s1�E AREA: 3� F- t .Ib ,.' k2 >c p,'? 1 ,l03 `� �4 TOP OF CAS GATE BOTTOM AREA: $� x t'2. t tr, 0,1 q - 3L /.� 4 ELEVAT[ON 74.27 ,S BARNSTA BLE GIS � � �. �7 � . m 10, SEPTIC SYSTEM SECTION ry 0 '( �J��1J 'Cove ft I" MIN l ��rintp,rrgr r ) _ _ -6 J f 1 �C [111)sth 'l�(� id, it feA Ok.t I -12 3 .�,,�n t »°� Cj(n Fuld �. r 72`( �! ,.�.'. p-BOX ! G / `•.J �J V� GAL 72.�° r1ar �Ic,�F •J SEPTIC TANK `6f &V tme ;) vS o c� 6 x' Cj 1 . - ,� 72. 7 tZ.•11.rviY,Z.(1'� �b 6095 �6t,17 Oa I povl�cA SITE AND SEWAGE PLAN LOCATION : Co O 5r �7LL cKof ts,�c � r� �t4' $A"IllI �181, 50 46u ��� PREPARED FOR : , )lVVl&L � ARREN LtV r � r n U M. R mom 12.It0 �146 ) �SG�t?� . 1140 S '� DARKEN M, MEYER, R.S. SCALE P.O. BOX 981 PATE i SANITAR\ (, F1 a.�r EAST SANDWICH, MA 02537 W DATE HEALTH AGENT Ph. (508) 362-2922 W