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Home My WebLink About0097 PONTIAC STREET - Health 97 PONTIAC STREET, HYANNIS A= 269 063.002 TOWN OF BARNSTABLE { LOCATION 14 Nrvr S SEWAGE #j,J$CX-C�id�J Vi ,LAGE 9 �OtA14C S-�a�A- ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 .D LEACHING FACILITY: (type) 4 P-16 6 tl (size) NO.OF BEDROOMS BUILDER OR OWNER PERMI'DATE: COMPLIANCE DATE: i Z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility )d -+ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A-- b Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin faci ' y) , A, o Feet Furnished by 4:�Ij I •--�-� e� t o , c r� 1 I'd A ' R Commonwealth of Massachusetts �c� ea�E Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe Sxret.,y ECEA -David B.Struhs Comminioner SUBSURFACE•SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �-,�� -57t CERTIFICATION ✓!,4 yj Property Addie#s:lr lgCS Address of Owner: Date of Inspection: G) —/,/— ?.- (If different) Name of Inspector: W.E. Robinson Sr. / Company Name, Address and Telephone Number: W.E. Robinson Septic Service j P.O. Box 1089 CERTIFICATION STATEMENT Ce�7nter77v77ille MA I certify that I have personally inspected the sewage dispos l 5 erg t 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 Signature: Iiv a• ( Date: 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, C,or D: A] ,SYSSTTEM PASSES: V 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 CO ITIONALLY PASSES: One or mo system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspetion. 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 im�rtinent. The system will pass in if the existing septic tank is replaced with a conforming septic tank as. a proved by the Board of Health. (revised 8/15/95). 1 One Winter Street ` c Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(61 292-5500 Printed on Recycled Paper { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: q 7 10m tl19 G r 7- Owner: s y/w Date of Inspection: /;,,_/ly j B] SYSTEM CONDITIONALLY PASSES (continued) _ wage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pi• (s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Boa d of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The sy tem required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspe ion if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION S REQUIRED BY THE BOARD OF HEALTH: Conditions exist whict 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 9NLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTE T THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ' _ Cesspool or privy is within 50 feet of a surface water Cesspool/OuNLESS privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FA THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS 76 TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a ept{c tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The sv ten, has a sgeptic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a ieptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 Ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage nto facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding f effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �- - CERTIFICATION (continued) Property Address: Owner: -5 y/a,9 f7 Date of Inspection: —9 D]SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 or privy is,below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen.and nitrate nitrogen. El LARGE SYST M FAILS: The ollowing criteria apply to large systems in addition to the criteria above: The e flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the en ronment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply th system is within 200 feet of a tributary to a surface drinking water supply t system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a ublic water supply well) The owner or operatL system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 d 6.00. Please consult the local regional office of the Department for further information. _ l (revised 6/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST q 7 /I C Y A/yam Property Address: cJ t ,`�� Owner: y Date of Inspection: Check if the following have been done: &A"umping information was requested of the owner, occupant, and Board of Health. "one 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 ag part of this inspection. 1/As built plans have been obtained and examined. Note if they are not available with N/A. e/T/he facility or dwelling was inspected for signs of sewage back-up. t!The system does not receive non-sanitary or industrial waste flow t/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. I/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 ovmer (and occupants,.if different from ovmer) were provided with information on the proper maintenance of Sub- Surface Disposal System. r 4 (revised 8/15/195) ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C e SYSTEM INFORMATION Property Address: �.�-►�i� `� 7' 1-1// h l S Owner: J y/7 4 h Date of Inspection: a_.f 9 FLOW CONDITIONS RESIDENTIAL: Design flow: ;31 ,gallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):_AC Laundry connected to system (yes or no):—Y--- Seasonal use (yes or no): Aof Water meter readings, if available: t Last date of occupancy: d "/el" COMMEACIAUI N D USTRI AL• Type of esta lishment: Design flow. allons/day Grease trap. sent: (yes or no)_ Industrial Wast Holding Tank present: (yes or no)_ Non-sanitary w ste discharged to the Title 5 system: (yes or no)_ Water meter re dings, if available: Last date of o upancy: OTHER: (Des ribe) Last date of u GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped. gallons Reason for pumping: TYPE OF STEM 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: V Sewage odors detected when arriving at the site: (yes or no) (revised 8/IS/95) 5 _ f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: g 7 1n hA 7' y gh Owner: `Sy 17 4/? Date of Inspection: j a - >y SEPTIC TANK: (locate on site plan) t ' Depth below grade: Material of construction: Vconcrete _metal _FRP—other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:a25 Scum thickness: 1 e ' Distance from top of scum to top of outlet tee or baffler , Distance from bottom of scum to bottom of outlet tee or baffler 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.) e a<V GREASE TRAP��lan) (locate on site 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 um to bonom or outiet tee or baffie: Comments: (recommendation for pu ping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of le age, etc.) (revised 19/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � �/A C Sr �-6/11 h/I f Owner: S y/1 $/) Date of Inspection: ) TIGHT OR sit OLDING TANK:_ (locate on plan) Depth below gr e: Material of const ction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: al Ions Design flow: allons/day Alarm level: Comments: (condition of inlet tee, ondition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, e\idence of solids carr)•o•.cr, evidence of leakage into or out of box, etc.) �1�:•� � PUMP CHAMBER: (locate on site plan) Pumps in working order:( s or no) Comments: (note condition of pump ch mber, condition of.pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: q t l` " - S- r Owner: S y/9,9 Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. / 1 leaching pits, number: (/ Pb ! G 0 0 S�� %� �; �,c�` /a.: �.®t✓tr4� 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 failure, level of ponding, condition of vegetation,etc.),4-0 CESSPOOLS: _ (locate on site plan Number and configur tion: Depth-top of liquid to let invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction Indication of groundwat c inflow (cesspo I must be pumped as part of inspection) Comments: (note condition f 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 s il, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .� SYSTEM INFORMATION (continued) Property Address: / Owner: �S/rJ As7 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i 1 1 1 i � � I `y- t DEPTH TO GROUNDWATER Depth to groundwater: Pp feet method of determination or approximation: Y (revised 8/15/95) 9 l ham£ L 0 C A T 1 69 SEWAGE PERMIT NO. V I L L A G E 106-3 vU Z INSTALLER'S NAME j ADDRESS IV t1 , 4. 1�c44, fir, e U I L D E R OR" OWNER �2 t 297 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Z bz � lV Lo � No...yS 1 Fes$.:: ....... THE COMMONWEALTH OF MASSACHUSETTS ' tl�ibav BOAR® OF HEALTH � ----Town.. .................._0F...Barnstable ....................................................................................... Appliratiou for Uhipogal Work.5 Tomitrurtiott Frrutit Application,is hereby made for a Permit to Construct (X ) or Repair ( } an Individual Sewage Disposal System at: Lot # 3a Pontiac Street, Hyannis , i iA -•-----------------------------•----•-------•-•-------•----•----------..-..--------- .............------------.....----•--•---._...------------------------... Loca io Add r ss or. Lo No._ • Capricorn Really_gust 76 r almouth t�oat�, t;yannis Owner Address Steve Lebel ------------ ----------••-...--•--•-•--•------------.._......---•--•--....----------.......-•-- ....-•--•-----•--•........----•-----..................--•---------------...........--------•-•---- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms----3.................. ... . _Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building .ranch..............No. of persons............................ Showers ( 2 ) Cafeteria ( ) Q, Other fixtures ----•--••-----------•-•-------•- W Design Flow.........5.5________________:_._...•------gallons per person per day. Total daily flow..........3 Q..........................gallons. W Septic Tank—Liquid' capacity_�_Q_Q.Qgallons Length$. Width4!10 Diameter................ Depth,5.'_8"..... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-__--_------........sq. ft. Seepage Pit No l__________________ Diameter-_____6._.__.._.. Depth below inlet-----6............ Total leaching area...266......sq. ft. Z - Other Distribution box ( ) Dosing tank ( ) Eldred e P,n ineeri: __......... Date_.__11_-2 81 Percolation Test Results Performed by____ ------_-------____ ___________g_.........._.._.__._.g .-........_.......__. �a Test Pit No. -_-_-minutes per inch Depth of Test Pit...12........... Depth to ground water2 QD.9----e iCounter— (s, Test Pit Nn Cl o. 2N/A........minutes per inch Depth of Test Pit.N/A_____.____. Depth to ground water.. V A............. a ----------------------------------------------------------------------------------------•--••-_...............................................Z............. : O Description of Soil--------- _ ?.-----•....I Q-aM...& --------------------------------------------- ------------------------------------------ v2 10 Medium yellow sand -- ------------ W .................. --------------------10......-___12-'--...-med.--_white---sand1tra.ces---of-_gravel no.__water.at__ 12 ' VNature 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 T 1TI,1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in- operation until a Cer ' to of C plia e as n issued by the board of lth. �' Signed. 4 Pre s.. •-••---912b184 +, / ate d O Application A ved B !111 '� Date Application:Disapproved for the following reasons----------------------------•---------------------------•--------------------•--•----...-•-••----..........------ ...................:...................................................................................-----•-••••••••-••••-------------------•-----•--•--••------•-•-•----------•--------------------- Date PermitNo......................................................... Issued_....................................................... Date t No.....0.......-c...... Fns.. °.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T-own...... ................OF....Barnstabl e Apptiratiou for Dhipoii al Works Towitrurtiou rrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Lot .#3A Pontiac Street, H�rannis , IriA __.................................................... - .... Locat'o Add ss or Lot No. Capricorn Reafty Trust 6S Falmouh Rd,___Hyanni....................... ---._... ........ .................................... Owner Address W Steve I,ebzl Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms....3.....................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building XE=h............ No. of persons............................ Showers ( 2) — Cafeteria ( ) p" Other fixtures ...................................... W Design Flow.........55---:-_---------------------gallons per person per day. Total daily flow..........33.Q..........................gallons. WSeptic Tank—Liquid'ca.pacity.l.4 OQgallons Length.8...6....... Width.4..10.... Diameter................ Depth_ ___$...... Disposal Trench—No- ----------------_- Width............. Total Length.................... Total leaching area--______-_.___---.--sq. ft. 3 Seepage Pit No--------------------- Diameter......6........... Depth below inlet...... Total leaching area....266.....sq. ft. Other.Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..... ldredge Engineering______.____ Date....z1.-25-81............. .... aj Test Pit No. 1_.2.,.D.....mfnutes per inch Depth of Test Pit....I !...._... Depth to ground waternQTle....eXIC O unt e r- �., / e Cc1i (s, Test Pit No. 2VA---__-•minutes per inch Depth of Test Pit.N�A.......... Depth to ground water___1?i��------------- O. .... .............-.................................................................---......--'....................................................... Description of Soil------. o f -..2.........l5?.a,W...s3c.... Qps o il---------------------------------------------------------------------------------------- x;' 2 _ 10 Medium yellow_-sand 10' - 12' med..•-•white---sand/trac_es_-of..•grayel/no••water..at• 12 ' 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 TITIE 5 of the State anitary Code— The undersigned further agrees not to place the system in operation until a Ce i to of mpli. ce has been issued'by the board of health. Pres. 9/26/84 ................................ Date lication Approved BY -•-------• ` f ---=- - .._. . ... .App a e Application Disapproved for the following reasons-------------------------•--•-•----------•---•----------------------------------•------••----•-•-----------...._. ----------------------------••-------.._...-•----------------.....---------------•-------...--------......_.....-----------------------------•----------------------------------------------------•--•--- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH {-' - ............T o.tiun.................OF........Bari .abla............................................ %TrrtifirFatr of Tumph aurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X ) or Repaired ( ) bY-------------------------------------------------Ste.ve.-.Le.hel.................................................................................................................... Installer Pontiac Street,. ----------------•••-B has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as des ribed in the application for Disposal Works Construction Permit No........ _-' .q-.�..__..-_.. dated_-...____�-- �5..... ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR E® AS A GUARANTE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... ......... 2 .I...................... Inspector b( -- .... -••-•--•-•---- .a. -. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f� .....TDIM........................OF.....Barest.able...................... ... c ry No......................... FEE......................... Disposal Works %'-falmitrurtion amit Permission is hereby granted..................ateve...L-e-b-al---•----------------------------••------------------........................................ to Construct �. ) or Repair ( ) an Individual Sewage Disposal System i Pontiac Street,......................•- at No. l,at- r� = ------ -------------- -y-a s! { ............................................... Street as shown on the application for Disposal Works Construction Permitallo ..rs ..._ Datled_J �! :"....................... ' ' {................................----------------..... �.............................. d Board of Health DATE.........--- FORM 1255 H 'es & ARREN. INC.. PUBLISHERS i f�T/C TAM AC Off? �L► . i A•f11 �, .�M/ G C'r A !" ' TH.gN 7�»' .� -� a�9 V �•: /� �T %� r l r� �I� r� 2�'Ol�!✓J El CONCA*A'7-,F "S`°O-M-' �o/ S C.�.k►C � r,V. �ITCf� / -FAVY C`A S /�OiY Ct�y. `Jr ,S/,+.q L L a,- U a 4-5 -0 x :4., ;�•�`s� Sly _fix PZ A s �. '�l��1 (Qom r 14e p o WASH 5MVE t .lip c . 7"AJV g . ,� • e e e e s °► •" O/ST t 314.0 s bVA.�tlEe� STONE e e t e v �e o a 0 • 0 0 / MECl,ST S. aJ-- SR S — 1 s� b e e •e o ® p lMVi'. T AT A91!/d.,DIM&:; F� _..- . ��. �,ra® !c: r�N�c : qg• F ALE ltli 7 ACRl A-J .�� " ATION aAR �AS�a v or _ .,SOIL, 1-06 OPP/1 're ` o Ej>.P�aAV3,36 0.41-10AV s011-7,F$7-. / suet sT 2 I4flld't�. �4 1e lRb �jTS r �L L?A 7r� ��' SOIL TEST ��dr r % �� AgY I�NG,F�� R. " Z nESUA.TS lITN� �4D 90T7'Q1?°P Ljoq CIWN-Cr AWN F'1T.2.�-�.S4c;k &r ��ra r� .�-S'.n5'orL " PAS-ACC®ZAo 6H *TAT4V l -- _ A?.#A Iljvcm TorAlt G W1N r AR,=A 2�i7 SQ '•FT. )CL-AwC®ILA 77aJV RA rfft*Z MlAfllNCH 18sE E�C �'/`Ol A/6 AREA SQ. FT .@ �.. Z -• t I.' . a OFM�1 s Mcn S�A,✓2 o 7Dl A F �� W 8 i t o SE , R r4 No 10951. G. 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GONTOUR O o oRSE. . t No.10951 O f ,y APPROVED a BOARD OF HEAL.TN civ�CQv 9 61ST� A P.�5 7"A:23 LE E1 o�FSS�ONAI E��\ z.. ®�►T� I. � � SCALE � „ . 2a ° /lW� 5 --�^--- -_._. 0 ....__...• �p�gpa �u IN, pd y L D R �.ie •EEG MFER a�i 67d Co a ' + F .� OERYIFY THAT T.NE 4� AOSED t�1 ,`�E .;. ..ram a �; ��.� Ro I d I � 0 ? ... rr.act BI.9I'LOIN ' 'S@ '0 9d. ®N `'� _ P6:"AN Cat . { 'LAND J ELCR�n!� 4 r . C N .dF3�`5 :T®' THE ZO LA , 5 . .R L1R �' , ® .® o � 73ran,+�sa A r �' " 'I I�� AI s : IaEE C6i: sYs WN p..