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1. 0CATION 4vtCidaEWAGE PERMIT N0.
INSTA UE 'S NAM i ADDRESS
t U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED r�•�
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Commonwealth of Massachusetts
. Tithe 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is
required for every Osterville MA 02655 4-16-13
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way_Please see completeness checklist at the and of the form.
Important:When A. General Information
filling out forms `�tpnubrruprr�.
on the computer, \������N•tH OF Mz+S���G��
use only the tab
1. Inspector: C
key to move your a y
cursor-do not I �� o•. Gn
.tames D.Sears .LAMES
key the returnY Name of Inspector v
CapewideEnterprises LLC o;
VQCompany Name . o
153 Commercial Street __-- ��er5rn `
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
S. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-16-13
toys Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or.DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,OOD gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
*'*.This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
LJ611 (j ' 1110111U
t5im•3113 Title 5 Offidel I ion Form:Subsurface Sevage Disposal System-Page 1 of 117
Apr 22 13 07;53a p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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.
Check the box for"yes", 'no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5 ns.3/13 Title 5 Offvial Inspection Form:Subsurface Savage Disposal System•Page 2 of 17
Apr 2213 07:53a p.3
Commonwealth of Massachusetts
v
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
i —
Property Address
Mark Chaffee
Owner Owner's Name
information is
required for every Osterville MA 02655 4-16-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)thatthe system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15irn.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3of 17
Apr 22 13 07:53a p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 P ys rY
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. City/Town stale Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)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 SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well_
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other.
.D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in Is less than 6" below invert or available volume is less
than V2 day flow /T
t5ins•2113 Tille 5 C idal Inspedion Form Subsurface Sewage Disposal System•Page 4 of 17
t.
Apr 22 13 07:54a p5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysts,performed at a DEIP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either°yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered 'yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 77
Apr 22 13 07:54a p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. Cityrrown state Zip Code Date of Irispedion
C. Checklist
Check if the following have been done.You must indicate 'yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design). 3 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Tile 5 Olfic4 Inspection Form:Subsuafaoe Seaaga Disposal System•Page 6 d 17
Apr 22 13 07:54a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required For every psterville MA 02655 4-16-13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and pit.
Number of current residents: 2---- —
Does residence have a garbage grinder? ❑ Yes Z No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available last 2 ears d 2011-7,00OGal's
g ' ( y usage g (gp »' 2012-4,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present .
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/personstsq.R., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ics•3113 Tde 5 Official Ins pedion Forrrc Subsurface Sewage Disposal System•Page 7 of 17
Apr 2213 07:55a p.8
Commonwealth of Massachusetts
G Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is Osterville MA 02655 4-16-13
required for every
page. City/Town State Zip Code Date of Inspection
Q. System Information (cont.)
Last date of occupancyluse: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 98109
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection form:Suosurface sewage oisposai System•Page a of 17
I
Apr 22 13 07:55a p,g
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is Osterville MA 02655 4-16-13
.required for every
page. Cdyfrown state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
1983 Permit#83-832
Were sewage odors detected when arriving at the site? Q Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
Depth below grade: 22"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass [] polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast
Sludge depth:
3"
15ins•3113 Title 5 Oficral Inspection Form Subsurface Sewage l3 sposal System•Page 9 0117
h Apr 22 13 07:55a p.10
Commonwealth.of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt_)
Distance from top of sludge to bottom of outlet tee or baffle 2T
1"
Scum thickness --
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank and outlet cover at 22"below grade w/inlet cover at 6". Tank at working level w/outlet tee.
No sign of leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance From bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
15ins-3/13 Title 5 Offical Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
- I
Apr 22 13 07:56a p.11
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owners Name
requir required
is Osterville MA 02655 4-16-13
required for every
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid ievels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow
gallons per day
Alarm present; ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
[Sins•3/t3 Tille 5 Official Inspection Fonrr Subsurface Sewage Disposal System•Page 11 of 17
Apr 22 13 07:56a p.12
Commonwealth of Massachusetts
Title a Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is OSteNille MA 02655 4-16-13
required for every
page, Cityf rovm State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16°-26" below grade w/one line out. Box is clean and solid . No sign of over
loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No`
Alarms in working order. ❑ Yes ❑ Noy`
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Fom i Subsurface Sewage Disposal System-Page 12 of 17
Apr 22 13 07:56a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number: —
❑ innovative/alternative system
Type/name of technology: --
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.),
Leaching is one 4'. precast pit WT stone. Pit and cover at 31"below grade, pit is wet on bottom.
No sign of.high stain line or solid carry over_ Walls are clean like new.
Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No
15ins•3113 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System-Page 13 of 17
Apr 221.3 07:57a p.14
Commonweafth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
t5ins•2113 Title 5 01111cal Inspection Form:Subsudace Sewage Disposal System•Page 14 of 17
Apr 22 13 07:57a
p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page_ City/Town State Zip Code Date of Inspedion
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Loca
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
2 3
%3 3 =
a � = mil ,
❑ A
3
@3 '
t5ins-3113 Tifle 5 Official inspection Form:Subsurface Sewaee Disposal System-Page 15 of
Apr 2213 07:57a p.16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Fortis- Not for Voluntary Assessments
290 Hickory Hill Circle
Property Address
Mark Chaffee
Owner Owner's Name
information is required for every Osterville MA 02655 4-16-13
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked,date of design plan reviewed: 1983
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
T.H_ on File B.O.H. 1983 no G.W. at 12'. Bottom of pit at 6'-6". Bottom of pit at 5'-6"above T.H.
Depth
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15i-s.3113 Title 5 Ofriolel Irspedion Forth:Subsurface Sewage Disposal System•Pane 16 of 17
Apr 22 13 07:58a p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 290 Hickory Hill Circle
Property Address
Mark Chaffee r
Owner owners Name
information is
required for every Osterville MA 02655 4-16-13
page. Citylrowm State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•W13 Title 5 Official Inspection Forn:Sutsurface Sewage Disposal System•Page 17 of 17
THE COMMONWEALTH OF MASSACHUSETTS FRis...A................
BOARD OF HEALTH
.............. .
a �vvlirativu for Diipoottl Hlorkii Tomaurtion Prrutit
pplication is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
......! .� .. .�r..rz ..........�sT----------------------- .. ............._..
....-----..
kL.ca;i..- d re r Lot No.
l� s�:....- Q..... �C....... � 7........................................................
` / Owner Address
a ................. �/_._..��/.. _ ......_.........._.................... .............................. ...........................................
Installer Address
� feet Type of Building Size Lot...........................S q.
Dwelling—No. of Bedrooms...._.....—. ..............:.............Expansion Attic of-� Garbage Grinder QUC)
�' e 0� Other—T yp of Building -00 .......... No. of persons......... ................. Showers (.9j — Cafeteria 0/0)
a' Other fixtures ..................................
W Design Flow....... .....6_._....gallons per person per day. Total daily flow___-------:5�.50.................gallons.
0: Septic Tank—Liqu d capacitv._i���gallons Length.....10..... Width...... ...... Diameter-----& Depth....4........
Disposal Trench—No. Width.................... Total Length.................... Total leaching area...A6.11.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..... 1.[i?� .�..... ��1 �.lr_/ .. Date_.... .......
aTest Pit No. 1....4.Zminutes per inch Depth of est Pit.................... Dept?to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------•-----------------------•--•----•-t .. ................... I .................................................................
O Description of Soil------- _-_ -.......� �!,✓L-•-t �{� s C- ----------------------------------------•-------------------•----....---------------
xI..... . . .__.
c, -- ..5....-•..... ................................................................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
t`
-------------------------------------------•--------------------------------------...------•-•--••---•----....--------------------------------------------------------------------------•---•-••••----
Agreement: "
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LI LL 5 of the State Sanitary 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.
Signe . ..-• ----•.. s ....... ... .... ----••-•------............._. /..
--- ... 3
ApplicationApproved By--•-•-------•-----......-'...... .......................................................... ........... -�.......
Date
Application Disapproved for the f ollo ing re ons. •-----•----•-----•---•------------------•-•-------------•-••-•---•------------.........._......---•---•----....
............................................•--------......................---.....---....--^---...-•---•---.............-•---.................................... .._........• ............•-
Date
PermitNo.......................................................- Issued.......................................................
Date
___—------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--------------- ............................................
Applirtttion for Diiipnottl Workii Tnnotrnr#inn rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
. --.....-
Location Address r or Lot No.
...........................................................
Owner Address
w �/ ,� ...................................................... ........................... ..........................................................
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........�...............................Expansion Attic (AJr,) Garbage Grinder (�Jo)
P4 Other—Type of Building -_- ......... No. of persons.......(.................. Showers ( L) — Cafeteria (N(,)
P4Other fixtures ....... ...........................................................................................................................................
w Design Flow........%:^. . ._._._5..:5.........gallons per person per day. Total daily flow........... ?_ r .................gallons.
94 Septic Tank—Liquid capacitv__L�`Ugallons Length-----dx ..... Width------k...... Diameter_____- ....... Depth....t_........
w p Width.................... Total Length..................._ Total leaching area _._..sq. ft.
x Disposal Trench—No...�J.l A.)�_..__ a'.•G_ _:`�
Seepage Pit No--------------------- Diameter.................... Depth below irilet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
1-4 �((Mr sic f e� Hr <P f i- /•�� Date (�! U
Percolation Test Results Performed by............. ........•r --..............._J--......_................ ----...=-..............................
�}
Test Pit No. I...._:�__�__minutes per inch Depth of `Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth o ground water........................
R+ •-•••-•-•-••-•-------•-••-••••......•--•.....•.•_-••••-•-•••••••------•----•--•---•..............•..........................................................
O Description of Soil........cr----,- =�=:..... I `- ='•�-L= `... 1 = -:a'7r
x
W ` `' 1.....F C ...._.J..�.1i ....--•----•-------------••-•----------•---•-•-------•-•------------•-......_.........--------.....
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 TITL- 5 of the State Sanitary 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.
Signed. -• . . •.... S.. ....
a- a -
Application Approved By•-•••.................... ........ ......... ... G/.
'---•--•-•-•.................................... . ......Date
Application Disapproved for the f ollo ing re sons:---------------•--.....--------•--------------------•---•-----•--------------......_....._.........-••---.......
-•-••••••-••••.•••-••••••...-••••-•-••-•...............•_._...-•-.•••....-•••••••••-----•-•--••...•••-•••-••--•••-•................•---•--•••-•-••••..•-•--••-••••••••••--••••......-••••-••-•-...•.....
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..7.�.........OF.......... .?/-.`2�7 ...............................
. �rrtif irtttp of f�nnt�rlittnrr
THIS IS TO CERTIFY, T4at the Individual Sewage Disposal System constructed ( or Repaired ( )
� -� .
by............./I/.....f ........................ .•••••--•---•-••----1----••----.....--•.....•••--•--•-..........-••-----•••-••--•--•-•--•---•••...........•----•-•••-••••-•-••--••.
Installer
at_---•- �•••-•• //f.F.j.:...........!l_....---------------�-'-T......-----------------------------------...........------XUA/RANTEE
........---------
has been installed in accor Once with the provisions of TIT F f The State Sanitaryed in the
application for Disposal Works Construction Permit No.�- .- ''.............. dated.. _.................
THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONST U AS AHAT THE
ION SATISFACTORY.
SYSTEM WILL U /
DATE.__.. �...... . ..�.............. :.......... ............•- Inspector.. ... ..........................................................................
{
THE COMMONWEALTH OF MASSACHUSETTS
BOARD {OF HEALTH
...............71}A L .......OF........4>.............................c (---••-..........••--•-...........
NIS.�`..�.� FEE... .............
Oftyi sttl Norkg Tnnstrnrtion ramit
Permission is h re by granted 1 ------------------ �-...--•------ --................-----
to Construct (kj or Repair ( ) an%�Individual Sewage Disposal System
at No. ....- � �
f---••-•••--.-•••••L - ......-•••-•......••-•-••---••. •..........................................
,� Street
as shown on/theplicat' n for Disposal Works Construction Permit No................. ated.:_..........__....._.....................
�� oard of HealthDATE....----•- /----------••-----•--------•---•------.-•---•-----•-------.
FORM 1255 A. M. SULKIN, INC., BOSTON
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EXISTWO CONTOUR --- 0 -- - a3
FINISHED SPOT ELEVATION ] A� d rn 107 3�1 /C / c���F
FINISHED CONTOUR 0 ------ 0 t RSE' OsT�=i?v/
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APPROVED , BOARD OF HEALTH Ago �isT�4 ��'`
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DATE AGENT e�� o •��aa
SCALES "�.. � . DATE, 77/2ts�/�-:3
LDREDGE ENGINEERING CO IN CLfEidTa�rsr,��
-----d I CERTIFY THAT THE PROPOSED
EGISTERE ZUGR
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CLVIL LAND CONFORMS TO THE ZONING LAWS
ENGINEER VE DR.BY '_ '�"I:_
OF BARNSTAB E MASS.
T12 MAIN STREET CH. BYE
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i
/.. NOTES: , ,
1.) CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS
&DIMENSIONS IN THE FIELD
3a-o 2.) CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS,
ABOVE ON GABLE NEW DETAILS,&FINISHES IN THE FIELD WITH OWNER
00 ❑E PATIO 3.) ROUGH OPENING HEAD HEIGHT OF WINDOWS AT
FIRST FLOOR TO BE V-8"ABOVE SUBFLOOR ,
14'a' 3'4' 3'-4^ o r o T-4" 3-4" 5'-,r 4.) ALL CONSTRUCTION TO CONFORM TO 780 CMR MASSACHUSETTS
❑ tB
STATE BUILDING CODE,8TH EDITION AMENDEMENT&IRC2009
B - g A6 D D D I i I 5.) 116 MPH EXPOSURE B WIND ZONE 2. ,
6.) ALL SHEETS OF PLYWOOD WALL SHEATHING TO BE INSTALLED VERTICALLY,
\ / I OR HORIZONTALLY W/BLOCKING AT EDGESI 3"EDGE/12"FIELD NAILING
J I I 7.) ALL LVL LUMBERIBEAMS TO.BE 1.9e U360 LOAD =
r I SEPTIC
I 8.) SEE CERTIFIED PLOT PLAN DEVELOPED BY YANKEE SURVEY FOR ALL
F I I PROPOSED&EXISTING DETAILS
A I I I 9.) :FOLLOW ALL MANUFACTURER'S SPECIFICATIONS FOR INSTALLATION OF
A4 a'-0' 4'-s^ a _ A I I ALL SIMPSON COMPONENTS,'
A4 I i I 1.0.) ALL CONCRETE USED FOR FOUNDATION WALLS,FOOTINGS&SLABS
A I FMoa x r---i p I ( I TO BE 3000 PSI w
sKYLIcI,T I i i I —/ I. 11.)VERIFY ALL PLUMBING&ELECTRICAL DETAILS W/OWNERS ON THE SITE
J LABovE I DwL--- —J CONSTRUCTION
t
L---J I VERIFY ALL / a
_ ---- BMANTELD 2 TIMBER I FRAMINGGTO BE SPRUCE/PINE/FIR NO 2 GRADE ..
GAS F.P.
ETAILS - Tn
T----- ylN� _—�__ ______ --_ --1 NEW - WlOWNERS
1 .)
CENTER O I I g I FAMILY / 13.)FOLLOW ALL REQUIREMENTS OF THE 110 MPH CHECKLIST_SUPPLIED
m O I ce I is ROOM /• ,14.)FOLLOW ALL REQUIREMENTS OF THE IECC2012 RESIDENTIAL ENERGY '
4
EFFICIENCY REQUIREMENTS&VERIFY ALL DETAILS WITH THE INSULATION
` I i INSTALLER/CONTRACTOR
Al I 08
�KVL CH I RELOCATED I 4 �T 15'.)ALL HEADERS TO BE 3-2 x 8's UNLESS OTHERWISE NOTED
�E /
OKY T i 3 F /_
ABOVE - KITCHENI - ti; / WINDOW'.'SCHEDULE
_ - I (VERIFY KITCHEN
I j LAYOUT W/OWNER) I 14•_e- / TYPEMANUFACTURER'S UNIT ROUGH OPENING REMARKS
7 I i REF I / ^t A ANDERSEN AR21 2'-0 5/8"x 1'-5 1/2 AWNING
/
3'$' � B TW21032 3'-0 1/8"x 3'-4 7/8" DOUBLEHUNG
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E A31 T-0 1/2"x 2'-0 5/8" AWNING
F •A251 2'-4_:7/8"x 2'-0 5/8'_ AWNING '
• - - I I - "
4'j: I 1.CONTRACTOR TO VERIFY ALL WINDOWS WITH OWNER AND ROUGH OPENINGS
o WITH WINDOW MANUFACTURER PRIOR TO ORDERING OF WINDOWS
"r �I' EXIST. 2.ANDERSEN 400 SERIES WINDOWS WHITE EXTERIOR
' HARDWARE
I I LOW-E HP 4 GLAZING W/SCREENS&METRO ,
DINING
MUDROOM qi O }
{ ----------- -=- -- •
_ ' '•�' •I � IECC2012 RESIDENTIAL ENERGY.EFFICIENCY, DETAILS
x EXIST. DOD
RS — BENCH --- -- I CLIMATE ZONE 5A(USE EITHER PRESCRIPTIVE VALUES OR RESCHECK CALCULATION
GARAGE
1 I TABLE 402.1.1 (MINIMUM PRESCRIPTIVE INSULATION&FENESTRATION REQUIREMENTS)
FENESTRATION SKYLIGHT CEILING WOOD FRAMED WALL FLOOR BASEMENT WALL BASEMENT SLAB CRAWL SPACE WALL
c- - - U-FACTOR U-FACTOR R-VALUE R-VALUE R-VALUE R-VALUE R-VALUE R-VALUE -
. ' EXIST. EXIST. '0.32. 0.60 49 20 30 - ,15/19- 10(2FT.DEEP) 15/19 e ,
! LIVING HALL
NOTES: ... -
" _ 1.R-VALUES ARE MINIMUMS&U-FACTORS ARE MAXIMUMS.
c 2.10/13 MEANS R=15 CONTINUOUS INSULATED SHEATHING ON THE INTERIOR OR EXTERIOR
OF THE HOME OR R=13 CAVITY INSULATION AT THE INTERIOR OF THE BASEMENT WALL
3.REFER TO IECC 2012 CHAPTER 4 FOR ALL INSULATION&ENERGY REQUIREMENTS - -
t
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43 BREWSTER ROAD °NS RRES N.'HEE,IMING RTHEC"`R"GT°R 1/4" = 1'-0"Ar WILL RE RESPONSIBLE FOR THE CONTENT
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W/2x4 KEY 8(1)a4HORIZONTAL EXISTING SUBFLOOR,(VERIFYINFIELD 1 .. BEAM SEEDetvL `BAR AT TOP 8 BOTTOM OF WALL .' . . : „:- _ - •r , v
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IN ESEDRAWINGSIF CONSTRUCTION -
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1 �. Ts DESIGNER OF ANY ER OMISSIONS.
PH. (508 274-1166 e' J'"'4 THESEDRAER
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THESE DRAWINGS REQUIRES THE WRITTEN
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"0. 15" INSTALL 5/8"SIMPSON TITEN HD ANCHOR BOLTS AT
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13'-W 4'-0" 1T-0" - 8" 9' PLACE BOLTS WITHIN 6"-16"OF EACH CORNER AND - -
TO A 8"MINIMUM DEPTH.BOLT LENGTH IS 10".
' 12'DA.CONC.SONOTUBES � � + -
TO 4'0"BELOW GRADE.USE - -
,i. - SOLID BLOCKING INt4l
SIMPSON ABU46 POST BASE 6-0'
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THE OUTSIDE TWO
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NEW ''" 1i I I VERIFY EXISTING SEPTIC TANK
O - "• I - LOCATION IN THE FIELD:THIS
LOCATION SHOWN IS FROM THE 8"x 8"x 1/2'STEEL PLATE ,
AS BUILT CARD - WELDED TO 3"x 3"x 3/8" _
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N d 3"CONC.SLAB W ,1' /. - _ STEEL COLUMN- t
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" TOP&BOTTOM -
- CRAWLSPACE "
EXIST. -NAILING SCHEDULE
BASEMENT 110 MPH EXPOSURE B WIND ZONE
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.' JOINT DESCRIPTION .` NO.OF COMMON NAILS NO.OF BOX NAILS .NAIL SPACING
..�„ .. .. � . ._. * _ _ "X• + .. A. _ .- - 'ROOF FRAMING: .. .
4 ' - +. - .' .- • _ BLOCKING TO RAFTER TOE NAILED ,. 2-6d 2-10d EACH END
RIM BOARD TO RAFTER(END NAILED) - 2-16 d 3-16d� EACH END
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WALL FRAMING: -
• - TOP PLATES AT INTERSECTIONS(FACE NAILED) - .4-16d 5-16d - -AT JOINTS
' EXIST, '' m'-• STUD TO STUD(FACE NAILED) - 2-16d 2-16d - 24"o.c.
• - GARAGE HEADER TO HEADER(FACE NAILED) - 16d 16d- 16"o.c.ALONG EDGES
FLOOR FRAMING r -
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- BLOCKING TO SILL OR TOP PLATE(TOE NAILED) 3-16d 4-16d EACH BLOCK
LEDGER STRIP TO BEAM OR GIRDER(FACE NAILED). 3•16d 4-18d - EACH JOIST
- - - JOIST ON LEDGER TO BEAM(TOE NAILED) - 3.8d 316d PER JOIST'
BAND JOIST TO JOIST(END NAILED) , 3.16d 4-16d. PER JOIST
BAND JOIST TO SILL OR TOP PLATE(TOE NAILEDO - - 2-16 d 3-16d - PER FOOT
. - - - ROOFSHEATHING:
.. c - S WOOD STRUCTURAL PANELS(PLYWOOD) - - - -
- RAFTERS OR TRUSSES SPACED UP TO 16"... 8d ,1 Od - 6'EDGEAr FIELD
RAFTERS OR TRUSSES SPACED OVER 16'os. - 8d' 1 Od - 4"EDGE/4"FIELD -
GABLE END WALL RAKE OR RAKE TRUSS W/O OVERHANG 8d 10d" B"EDGE/B"FIELD
GABLE END WALL RAKE OR RAKE TRUSS - 8d 10d _ 8"EDGE/('FIELD -
i W/STRUCTURAL OUTLOOKERS
———————— GABLE END WALL RAKE OR RAKE TRUSS W/LOOKOUT BLOCKS _8d 10d 4"EDGE/4-FIELD
' -CEILING SHEATHING: `—
GYPSUM WALLBOARD 5d COOLERS 7"EDGE/10"FIELD
. ' WALL SHEATHING
.
- - - - - STUDS SPACED UP TO 24'o.c. „ 8d .- 10d 3"EDGEN2"FIELD
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r - - 1/2"GYPSUM WALLBOARD 5d'COOLERS • — 7"EDGE/10"FIELD
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B�� COTUIT BAY DESIGN. Lac NEW ADDITION/REMODELING FOR. THE DESIGNER SHALISENOTffIEDIFANY SCALE : DRAWING)RR
ORSOR OMISSIONS ARE FOUND ON�y,. E_D_TIONGEIISUx.DINGOOR1/4" � 11-01.
43 BREWSTER ROAD r �RgC� ES RESPoNSIB EFORT ECON..�((lll"` THESE D.....B E CONSTRUCTIONMASHPE`EMA. 02649 CHAFFEE/KNEELAND RESIDENCE . �8-iG 7 MME RAWINS OUT NOLELYFOR TH
PH. (508)274-1166 y DESIGNER
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Sod i THESE DRAWINGS ARE SO 0.FOR THE USE
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( 290 HICKORY HILL CIRCLE OSTERVILLE MA OFTHEOWNERNOTEDANY O HEECTIR USE OF
FAX 50 539-9402 OONSAARCHIT T OOF TA EEE GHT�10TET o„ 5/21/2015
CONSENT OF THE DESIGNER UNDER THE
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TYP. ROOF CONST.
F - - - -2 x 12 ROOF RAFTERS @ 18"o.c.
-5/8"CDX PLYWOOD ROOF SHEATHING
-ASPHALT ROOF SHINGLES
- - -t - - -
.. - -15L8.FELT PAPER -
a SPRAY FOAM INSULATION -
@ SLOPED CEILINGS(R=49) «
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SIMPSON H 2.5 HURRICANE CLIPS
AT ALL RAFTER ENDS '
-ICE/WATER SHIELD AT BOTTOM
3'0"OF ROOF
-WIND WASH BARRIERS
-ALUMINUM DRIP EDGE _
- GABLE END WALL TO -
- _ 4. BE BALLOON FRAMED -
TOP OF PLATE EXIST.CEILING JOISTS NEW W72 z 40 STEEL BEAM. -
'., TYP.WALL CONST
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8.TYVEK VAPOR BARRIER
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c _ RIDGESEAM - - P.T.2x8SILL _
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OM RIDGE DOWN TO HEADER 9"BATE INSULATION.(R=30)
NEW
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IF REQUIRED).
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SEPTIC - -
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.
ERRORS OR OML ONS ARE FOUND ON
I � THESE DRAWINGS PRIOR TO START OF '
CONSTRUCTION THE BURRING CONTRACTOR 1/41' - 1 1-01,
43 BREWSTER ROAD WILL BE
FOR
WNSTRUCOCTONT
COMMENCES WITHOUT NOTIFYING THE
77�
MASHPEE MA. 02649 DESIGN EROFANYERRORSOROMISSIONS.
CHAFFEE/KNEELAND RESIDENCE . s OFTE DRAWINGS ARE OWNERNOTED. NYOL OR USE OF DATE . ��
PH. (508)274-1166 " s � ,r °ESE oRAWIENGS REQUIRES THE WRITfEON
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ARCHITECTURAL COPYRIGHT PROTECTION
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