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HomeMy WebLinkAbout0028 GOOSEBERRY LANE - Health _ 28 Gooseberry A= 102-077 _ / 1 1 �- YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 yearsi. A business certificate ONLY REGISTERS YOUR NAME in town (w.hich you must do by M.G.L.-it does not give you permission t--o erate.) You must first obtain the necessary signatures on this form at 200 Main,St., Hyannisf i;;,. Tale the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601. (Town Hallj and get the Business Certificate that i ' . tir required by law. DATE: dc-�I�D' Fill in please: a, ' APPLICANT'S YOUR NAME/S: 9 /Gh 'z- L �I L`� ^:i!?: a%;r •ti;i:".•t ' ti BUSINESS YOUR HOME ADDRESS: Csc �"3 ,y(L �L /j'iI.'' S ` �.l�y^1�1 /�1 yA� ,- _`I 1 lam/, Y•L t•n.. ifi �,•'1 :l i1•�y Y�'�V�V 1 Vq I� J �l I• -V J-1LW �V�^� L '-fir • y�;rti:: 'jl �Lt+li il:_�n,{J4/1 TELEPHONE # Home Telephone Number 't :i �J!ivii�1_'4�r� OR E I N #: 9 - vZr ,� E-MAIL: i etv � c G` �(r rr=J 4i•.'.I ki:' Yry'1i'./n i1'•: `� R. CS%h NAME OF CORPORATION: ' NAME OF-NEW BUSINESS 6_&VPT' TYPE OF BUSINESS I-FbJSC IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS. a^ b �'� L �'1` �' MAP/PARCEL NUMBER P� -[Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regufations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - corner of Yarmouth Rd. & Main Street) to make sure'you have the appropriate permits and licenses required to legally operate yourTiusiness in this town. 1. BUILDING CDMIVIISSIO ER'S OFFICE MUST COMPLY WITH HOME O�'�.`�UF-A:' '';�I� This individual h s bee infor ed V-n-,� er ire uire Brits that pertain to this type of business. RULES AND REGULATIONS, FAILUHE TO ut orj d ignatur * COMPLY MAY RESULT IN FINES, MMENT —�� l o- - <J 2. .BOARD OF H LTH This individual 7/ uthorized een •nforme oft e,pprmit requirements that pertain to this type of business. - ' Signature** COMMENTS:. 3. CONSUMER AFFAIRS [LICENSING AUTHORITY] This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: . - i Date: i /��"/ 1� TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM i NAME OFBUSINESS: L , nyiTt PA i A BUSINESS LOCATION: (9LE s-7 iM���ia.� S ��S. INVENTORY MAILING ADDRESS: P•C> a vh b- 1Z ✓h Af 5-MA S ►M AL S, TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: `7'7 -aa k-/C? C. MSDS ON SITE? TYPE OF BUSINESS: h6 u S t i�i4�h��►� INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product, Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts(Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals(Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials s c TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: L t7s yi-Tr BUSINESS LOCATION: a"i� L-&) !M/kc5to1 S ✓t'I ( 4S, INVENTORY MAILING ADDRESS: P-0 a ah (->Q ilh /fir sin S M<<<S, TOTAL AMOUNT: TELEPHONE NUMBER: '77q - CONTACT PERSON: tM iclnu e Lt Ays'1't EMERGENCY CONTACT TELEPHONE NUMBER: �77y aa�-l67 MSDS ON SITE? TYPE OF BUSINESS: Husf za, *n5 INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals(Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride)- ❑ NEW ❑ USED! t Any other products with poison"labels ' (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials TOWN OF BARNSTABLE S G se e L SEWAGE # ZL !7/ LOCATION .Z � � R iC V A VII.L'AGE ASSESSOR'S MAP &LOT-JD-7 INSTALLER'S NAME&PHONE NO. J M a SO"' SEP`OC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF,BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: - _ 9 7 COMPLIANCE DATE: g? Separaii.on Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private'Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by l r rG i No. �'' Fee� 50. 00 THE COMMONWEALTH OF MAS/ACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for Migaal 6potem Construction Permit Application for a Permit to Construct( )Repair�X)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No.2 8 Gooseberry Lane Owner's Name,Address and Tel.No. Robert Thompson Marstons Mills,Mass . 02648 28 GooseberryLane Assessor's Map/Parcel Marstons Mills Mass . 02648 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 Po.P.Macomber &vSon Inc. J.P.Macomber & Son Inc. x 66 Centerville,Mass . 02632 Box 66 Centerville ,Mass . 0263.2 Type of Building: DwellingXXXNo.of Bedrooms 3 Lot Size sq.ft. Garbage GrinderUO ) Other Type of Building P E 4 No.of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 0 gallons per day. Calculated daily flow 1 1 0x3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1 000 Type of S.A.S.Existing 61 x8 t pit Description of Soil Medium sand with stones ; Nature of Repairs or Alterations(Answer when applicable) Add i n g 2— 500 gallon concrete chambers to the existing_system. 241x10tx2t Date last inspected: 5/2 8/9 7 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by thiYX f alth. 6/2/9 7 Signed Date Application Approved by Date 2! _ZZ Application Disapproved for the following reasons Permit No. Date Issued �jG Now Fee $ 50. 00 .. ""' THE COMMONWEALTH OF MAS/ACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprtcatfon for 30topooal *pgtem Cow5tructton Vermtt Application for a Permit to Construct( )Repair P)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.28 Gooseberry Lane Owner's Name,Address and Tel.No. Robert Thompson Marstons Mills,Mass.02648 -28 Gooseberry Lane Assessor's Map/Parcel 02648 Marstons Mills,Mass. Installer's Name,Address,and Tel.No. 508-775-3338 Designer's Name,Address and Tel.No. 08-77 —3338 .P.Macomber &vSon Inc. J.P.Macomber & Son Inc. ox 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XXXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder NO) Other Type of Building RES No.of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 1 1 Ox3 gallons. Plan Date Number of sheets Revision Date Title /f Size of Septic Tank Existing 1000 Type of S.A.S. Existing 61x8l pit Description of Soil Medium sand with stones; �- Nature of Repairs or Alterations(Answer when applicable) Adding 2— 500 gallon concrete chambers to the existing system. 241x10tx2t Date last inspected:' 5/2 8/9 7 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu "d by thisVoof alth. 6/2/97 Signed/ Date Application Approved by Date lcl�'W� � Application Disapproved for the following reasons Permit No. r Date Issued r...- G "" --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtftcate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired XX )Upgraded( ) Abandoned( )by J•P.Macomber & Son Inc. at 28 Gooseberry Lane Marstons MI11s,Mass. as been constructed with the rov��ssio�s of Titl 5 and e fqr Disposal System Construction Permit N dated InstallerpF'Y.MacoID�er ion "lnc y Designer The issuance of this pe t shall not be construed as a guarantee that the system will function as designed. Date 7 C Inspector C Z o ----- ---------------------- $50. 00 . ;, Fee is THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwtgpogaf *pttem Congtructton Vermtt Permission is hereby granted to Construct( )Repair�'XX)Upgrade( ))Abandon( ) System located at 28 Gooseberry Lane Tars ons Mi11s,Mass. 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:Construc 'pn must be completed within three years of the date of ti permit. Date: /� Approved I CERTIFICATION Or SKETCII AND APPLICATION FOR A DISP .I., WORKS CONSTRUCTION PC, IZ.�•11'1' (1V1'I'tlOU'I' DESIGNED PLANS) I Joseph P.Maeomber Jr. :t ccrtily that tlty application for disposal works construction permit signed by ntc ;:::ted _ 6/2/97 , concerning the priperty located at 28 Gooseberry Lane Marstons Mills meets all of the following criteria: sC • There are no wetlands within 300 fcct of the proposed septic s'�stem • There are no private wells within 151 tcct of the proposed septic system • The observed groundwater table t fccl or greater bclo%v the bottom of the leaching facility There is no increase in flow and/or chanbc in use proposed �— • There are no variances requested or nccded. SIGNED : JMA-20Z'/-/ DATE: 6/2/97 LiCEN SEPTIC SYS'fE,'vl IivS'i'ALLEIt 1N'1'1-iE T01YN OF BARNSTABLE NUMBER 47 (Attach a sketch plan of the proposed s)stem. Also if the licensed installer posesses a ccrt.ified plot plan, this plan should be sAmitted). Existing Distribution Existing 1000 gallon box. precast pit . 2-new 500 gallon concrete chambers Existing 1000 gallon septic tank. v' -^ TOWN OF BARNSTABLE LOCATION .Z /' GO O SC e eA R V L A SEWAGE # VILLAGE 9!L IY� r �� ASSESSOR'S MAP&LOT . 0 INSTALLER'S NAME&PHONE NO. A4 A C©M 8e/f sON SEPTIC TANK CAPACITY ` 0.0 O LEACHING FACILITY: (type) .`� FL64j C H,4 MRCP(size) oB cr NO.OF BEDROOMS 3 BUILDER OR OWNER Rp PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by •'r k 9 aIA� ry so lea/ - f_ TOWN OF BARNSTABLE LOCAVION 1AVe- SEWAGE A�W� VILLAGE 0:9i41-Sfad f �i�S ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lodl) LEACHING FACILITY: (type) B �` e7°'" (size) I®� NO.OF BEDROOMS ` ) BUILDER OR OWNER A[.) PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o 1 hin acility) Feet Furnished by �d / � s .z��9� A 7 �,rl�r� 0 Aa 2 S G dose13AAR)e L'.9 r 77 V Conunorrweatth of Mossachuselts M . , 9 Executive Office of Environmental Affairs Department of Environmental Protec 'onf �� F.Weld J U N 1 0 1997 T`- r Cox. TOWN OF A Paul Gllucc! S HfALTHOEPIh.` a�` $ a A ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI PART A CERTIFICATION Prvp.rtyAddress 28 Gooseberry Lane Marstons MillsAdd"..ofOwner. Data of lwP--oUoc6 5/2 8/9 7 (11 dittereat) Name olla.pootor. Joseph P.Macomber Jr. Company N&=e,A,ddresa aaa Telephone Number. J.P.Macomber & Son Inc. 508-775-3338 BQx 66 Centerville ,Mass. 02632 CERTIFICATION STATEMENT I oartijy that I b.av personally impected the Sewage disposal system at this address had that the information reported blow is true,aocurau and amp" as a the time of inspection. The inspection was performed based on my training Lad experience in the proper Ammon Lad n.rote^ ^a Of onaiu"W&CS disposal eystems. The ryrum: _. Passes . Conditionally Passes ..ds Further Evahtation By the Local Approving Authority _ PaII� f J Inspector's SlInaturK L� 6 Dacer 62- �e— 17 The System Iasp.cxor Shall rubmit a Copy of this inspection report to tha Approving Authority within thirty(30)days of oomp)rting this iarp.cctioa If the rysum L a Shared gstam or has a design flow of 10,000 gpd or greater,the impactor and the System owaar shall submit the report to the appropriata regional oMce of the Departm.at of Eaviroamaatal Protaction. The original Should be scat to the sysum owner wd copies seat to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A. B, C, or D: I Ss u[ t/0� �o r?7 A) SYSTEM PASSES: CO M et 0 !p l/9/ _V I bare not found aryy information which indicates that the system violet*$any of the failure criuria u deflaad in 310 CUR 15.308. Aryy UDure crit"not evaluated are iadicaud below. B) SYSTEM CONDITIONALLY PASSES: �a On or nory rystem compoaaau need to be replaced or repaired. The system,upon Completion of the replaosmaat or repair, paasa inspection. Indicate yee, ao, or not deu=dned(Y, N, or ND). D«cribe basis of detarminatioa in all iasuw". If"not detarmiaar,explain why hot) The septic tank is metal, CM:ked,Structurally uasottnd,chows subtaatW infiltration or cautmtion,.or tank failure L Imminent. The ryrum will pass inspection if the exirting Septic teak is replaced with a ponforming septic task as approved b7 the Board of Health. (reyl sed.11/03/95) 1 One Wlnur Strut a 8oston, MaSSachu►etts 02108 a FAX(617)556-1049 a Telephone(617)292•53t)0 �� Pmid an R K4d/apse SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinted) Prop.rtyAddr a 28 Gooseberry Lane Marstons Mills ,Mass . Owner. Bob Thompson Dat& of Ia.p.c40`5/28/97 B)SYSTEU CONDITIONALLY PASSES (ooatiawd) LL1 sevage backup or brxk"or bo static watat 1rw1 obwrnd In the dfstr�ban L duo to b:okaa or obWWAd pip.(I) or du to a brckatt, nettled or uarvan distAlution boa. The astam w1D pans inspection if(with approval of the Board of H.ahh). brok.n pipe(&)are replaced obstruction is tanwnd dirtributloa box is Halle or replace Tha gstam rquired pumpiay more than four tlmee a y"r duo to broken or obatructad pip.(&). Tb&gstam Will paaa irip.cticn if(with approval of the Board of Health): broken pipe(s)are replace obstruction is removed C) FURTMM EVALUATION IS REQUIRED BY THE BOARD OF HEALTHs Coaditioas exist which require Atrthar evaluation by th& Board of Health in ord&r to detarmiae if the systam is Ealing to protpa the Public health, aafsty and the anviroamant. 1) 6YSTBld WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 18 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND BAY=AND THE ZXVIRONMEN'n ��� C"spool or privy is within 60 feat of a surface water C",pool or privy is within 60 f1t1of a bordarLng vsptated wetland or a salt marah. 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE) DETY E9 THAT THE SYSTEM 19 FUNCTIONING 1N A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The s7st4m has &aaptia teak and aoil absorption gstam and is within 100 fist to a surface water supply or ue uury to a surface water supply'. The s744= W a wptk task and aoD absorption system and is within a Iona I of a public wat&r supply wall The system has a septic tank and&oil fbaorption system and Is within 60 feet of a private water supply wa1L The gstam has a"ptic tank and sol absorption system aad is kas than 100 fart but 60 f..t or mare from a prrvata water "ppb' w*11, unl++a a well water analysis for coliform barx&ria and volatile orgLnk compounds iadieas&a that tba wall is &,W tom pollution from that facility aad th& psewacs of aasmoais aitrogaa Lad nkmto nitropm is equal to or lee& than 6 ppm. 7) OTE ZR (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Ad&-": 28 Gooseberry Lane Marstons Mills ,Mass . Owner. Bob Thompson Date of La:pootion: 5/2 8/97 D) SYBTF_'d FAILS: I fary drt,x:nined that the system violates one or morn of tbs following failure aitaria as dsiind in 310 CUR 16.303. The basis for this d:- m.inatioa is idantisad below. The Board of Health should be coutacW to determins what will be nsaasa7 to oor:nct the failw-e. - 1f Y i 3.a.:kup of sswage into facility or system componant due to as overloaded or clogged SAS or osaspooL ? Discbs.r•ge or ponding of effluent to the surface of the Around or surface watars due to an overloaded or clogged SAS or �.opool C s tic liquid level in tht distributionox b above outlet invest due to an overloaded or clogged SAS or pool. 1_quid depth in coo-pool is Is"than 6'below invert or available volume is Isar than 112 day Dow. L o R;quirsd pumping more than / times in the last year=due to clogged or obstructed pipe(s). ii.Lmber of times pumper.�. tmay portion of the Soil Absorption 3ystam, cesspool or privy is babes the groundwater elevation t :,ay portion of a cesspool or privy is within 100 feet of a surface water supply or trt�utary to•surface water supply. ,may portion of a cesspool or privy is within a Zone I of a public wall. �(Y? Any portion of a cesspool or privy is within 60 feet of a private water suppby well. I.n7 portion of a cesspool or privy is laces than 100 feet but greater than 60 feet buns a private water supply wall with no 1'"ptable water quality analysis. If the wsll has been analysed to be adaptable,attach copy of well water analysis for mhform bacteria,volatile organic compounds,•amnwnia nitrogen and nitrate nitrogen. E)LAROE SYSTEM' FAILS: T..4 follo,:s_r criteria apply to large systems in addition to the criteria above: T—t sync y i->r a facility with a design Dow of 10,000 gpd or greater(Large System)and the system is a signiticaat threat to pubru li.i__:t.h as-,; t-tety and the eavironmant because one or more of the following conditions gist: >+ dyatam L within 400 fast of a surface drinking water supply t.- ryxtem is within 200 fast of a tributary to a surface drinking water supply r 0 r ;yutem is locatad in a nitrogen sensitive area Ontarim Wollhaad Protection Area MA)or a mapped Zone 11 of a public w�,_ar supply well) The owaar upsrc.s..rr cf s_qy such system shall bring the system and'facility Law full compliance with the groundwater treatment program rquimmsni, of 314 ChiR 6.00 and 6.00. Plae" consult the local regional oface of the Department for further information., (revised 11/03/9.) 3 SUBSURFACE SEWAGE DISPOSAL MTEM INSPECTION FORM PART B CHECKLIST pr,perty,ddre.a 28 Gooseberry Lane Marstons Mills ,Mass . owner.. Bob Thompson Date of Iaspeotion:5/2 8/9 7 ' Chack it the following have been doe.: 9Pumpiag information was requested of the owner,occupant,and Board of Health. ZNoae of the system compona4ts have been pumped for at least two weeks and the system has been receiving normal flow rate that period. Large vob="of water have not bees introduced into the system reosatb or as part of this inspection. ZA-1built plans have base obtained and roman-a Note if thq are not available with N/A. .!G7 U UcMty or dwelling was inspected for aigas of"wags back-up. jt The systam does rot rvcal"non-sanitary or industrial waste flow ZTk,site was inspected for signs of breakout. 4All system component.,&luding the Soll Absorption System,have been located on the site. z7W"ptic tank manholes wore uncpvwv4 opened,and the interior of the septic tank was laspected for condition of baIDas or toes, material of construction, dims&f as,depth of liquid,depth of sludge,depth of eaten ZTb4.� `b4 size and locatioa of the Soil Absorption System on the site has been determined based on existing information or cep ' ted by non-intrusive methods. The tac4ity owner(and owipants, if dilfervat from owner)were provided with information on the proper maiata of Sub. 8urfaos Disposal System. (revised 11/03/95) 4 51 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 28 Gooseberry Lane Marstons Mills Owner: Bob Thompson Date of Inspection:5/2 8/9 7 FLOW CONDITIONS RESIDENTIAL: Design flow: YO Q.p ./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): ,L') Laundry connected to system (yes or no):4 Seasonal use (yes or no): ILj� Water meter readings, if available (last two (2) year usage (gpd): Lgor= 4/R" 0 S Sump Pump (yes or no):AZ2_ )Q Vb — 3%Ao-0,4A4-V4 Az rW 6, ,V Last date of occupancy: 54-V COMMERCIAUINDUSTRIAL• Type of establishment: nJ Design flow:A�9 allon5/day Grease trap present: (yes or no)A)Z� Industrial Waste Holding Tank present: (yes or no)_1 Non-sanitary waste discharged to the Title 5 system. (yes or no)lJ& Water meter readings, if available:�.�Q A -Last date of occupancy: OTHER: (Describe) NBC' Last date of occupancy GENERAL INFORMATION PUMPING RE ORDS and so fe o informati Ily S System pumped as part of inspects n: (yes or no)4,46 If yes, volume pumped: gallons Reason for pumping: TYPE %SYSTEM yJ Septic tank/distribution box/soil absorption system A,M_ Single cesspool __,VOverflow cesspool Privy Z//_Shared system (yes or no) (if yes, attach previous inspection records, if any) ,V1d I/A Technology etc. Copy of up to date contract? Other X-11 4 APPROXIMATE AGE of all components, date installed (if known) and source of information: /977 6 La 0 Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Pay 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address; 28 Gooseberry Lane Marstons Mills ,Mass . Owner: Bob Thompson Date of Inspection:5 2 8/9 7 BUILDING SEWER: (locate on site plan) Depth below grade: �6 Material of construction: _cast iron Z40 PVC — other (explain) Distance from private water supply well or suction line y)4?Rr --UiCe T'rA47- e vc AerrSie, Diameter / Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:ffo Qt��✓4-��5 (locate on site plan) Depth below grader � Material of construction: Vconcrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age, .g Is age confirmed by Certificate of Compliance 444 (Yes/No) Dimensions: 6�I�D�'ri `✓ , 7 /�t�1 G/ /S �id�, Sludge depth._ �-- Distance from top of sludge to bottom of outlet tee or baffle/��_ Scum thickness: Distance from top of scum to top of outlet tee or baffle:,�e_ Distance from bottom of scum to bottom of outlet tee or baffle:��� How dimensions were determined: Meas_u,red with a tape measure and probe rods . Comments: (recommendation for pumping, conditio.R of inlet and utlet tees or baffles depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Pump tant every. 2-� years: Inlet and outlet tees are in place :Liquid levei at outiet invert over:Tank is structurall soun ank shows no suns of leakage. GREASE TRAP:_Z221JC). (locate-on site plan) Depth below grader Material of construction:.04concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: _A),9 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.) Grease trap is not present. (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oonalnued) propertyAddr•em 28 Gooseberry Lane Marstons Mills ,Mass . O„nar. Bob Thompson Date of Inspection:5/2 8/9 7 TIGHT OR HOLDING TANX%eVe- Uoct•an site plan) • Depth belaw v%&-� Material of oonsCn,ctiom:.G/ooncret._p�.tal--'RP_othexuplaw V Dimensions: 1)A Capeat�: AlA gallons Design flow Wday Alarm level: ill Comments (condition of inlet tee,condition of alarm and float switch",etc.) T,j W'h+_ nr hnl i rQ +.arks amp nn+.T DISTRIBUTION BOX-Z Gocau cc site plan) Depth of liquid level above outlet invert: 'i Commen33tt�-:s�..mo� too .mac.�f.off, �istributionboxo' level : Bos one lateral: Touhterers) evi ence o solids curry over:No evi(lence of Leakage in or out of the box. PUMP CHAMBE&,d, Gt_ (locate on site plan) Pumps in working order.(yes or ao)__,L2d Comments: (Hots condition of pump chamber,condition of pumps and appurtenances,•tc�) (revised 11/03/95) 7 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oan auwd) pro 28 Gooseberry Lane Marstons Mi11s ,Mass . OWD46n Bob Thompson D,u of Inap.otloat 5/2 8/9 7 ' SOIL ABSORPTION 6YW= OWxz Oomu cc sho plan,If poraiblr;asoavad=not nqui:vd,but may ba appradnAted b7 twadatruaiw aejoda) It not dowrmiad to be prw4A uplain: Type: L"Woj ptt+, number r l+,aehias eL,mbere,numbs. Lachia j pllai.+,aumbar. 1�achla j trsacA�,numbar,ka�th: ls.cain j tLM+ aumbar, wwtow o.espool, aumbw Comm.at.:(note ooadltioa of coil,�of h,�drsulie 4tkurr,lawl of poadte�,condition of v+�atation,rta.) Sn; 1 , CP.P ;�.qgP 2A -ThPrP arp si gnp pf hydrate i n ure •�ste water is +1,o ; r„ r o + pi pa +n tLe „i + 11 vegetation is normal. CESSPOOLS:& ' OOcate CM dw pL►W Nambsr•ad ooaligu tioa:_ 1724 Depth-top of HquW to ialrt invrrt Depth d solids LVar Depth od sum lyar. Dims d=.of cwspool:_ n)A 3dataiala as ooastsuctiOa_ A A Indiati—of pvuadwata ) iafla.(asapool must be pumpd as part of iaap.atioa) CessiDoo s are not present - Commaate:(nou ooadhion of soft, 4pi of lvdrsulie UM^lrval of poudinL condition of v%votation,ate.) reog innl c arP nnt, ;)resent x PRIVYt L ;o Good an eu PUZ) HaLarkla of 00"Ouct1=1 Depth Cammsata:(sots c=did=Of aoi>,aiPa of Wmulie faQurr,Lvrl of poadi &condition of"putioa,ik.) Pr; vv is not present `V (rrvlsed 11/03/95), + G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two ,permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supp v comes into house) a �o o (reviaad 04/25/97) Page 5 of 10 54 I ► _ P 1 U) vi 7/ z z_/-77 5G I 7-46%157 w17V6,S. 60 ar PAvC "URAAy Z4-77 c �J TEST NoGE 4 _._._._._.. — rc P• 0 ! -� I• - T C: 7f D IPG li '� �NJ. �'4• ZS 6 T L r^ o 1 y � �,. •..r� % 7 S ° - CEQTIIF'tEC7 pl.bT '{�L".X�1�:� .:- _ tOCAT1O" �1ARSTcNS t'���LS. Mf rYbATM /zs / 7'. I C6RTIF�{ T1-1A7 TN(:= F''vNt, A-rloKk ,,UCW ) Pt--A1J R�FcRE►JGE 1-I�R6�o►J SUN\PL�(S W 1 i A T►-IG 51Gn.LI►..lir L O T SS A1JU SFTC' CIC QEQU1eEN��u�S 0; TNT 1;3ooK 13 � F/\C9E ZS ,. PATE? �5 "1 � �' �� •�.�� - �--_...._.�c g,�xTcu. �. ►AYE 1QC-- REGlStz1Z�D 1-a.1.tp Sua�v�`foe� T1415 C�c A1--1 1; �avT �n���v v�-► /�cJ OSTE�LVIL1.� u MaSS� uJSrQ(JM�---t,jr APPLICA.ti1T t,k)r plc. U•,l_c-) ru f 11 y 1v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAitT C SYSTEM INFORk1I TION (continued) Property Address:. 28 Gooseberry Lane Marstons Mills ,Mass . Owner: Bob Thompson Date of Inspection: 5/2 8/9 7 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwatef i:ievation: Obtained from Design Plans on record *'d' Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Ground,.•.::.er Elevation. Must be completed) Checked engineered drawn plans . Installed many systems in this'development. House on high ground. (revised 04/25/97) Page of 10 • •.w.n,�.-n,�r!T,� n►ru+r•nAwl�-nn a�R./�r1rR1"1.�.►l.f.�wn�.s7iAlwr�n�l1 •. TOWN OF Barnstable BOARD OF HEALTH SUDSURFACF SEWAGE? DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION � h_..,.,........,.-,.,n-.-.•..,..r..n,rnn,,,r,..,..,.�r...•-.,.•,v.nr..n..�•--.•........wr+.�..n.v,.., ..n, . r,•,r..,.,.,�• -TYPL OR PAINT CLEAALY- PROPERTY INSPECTED STREET ADDRESS 28 Gooseberry Lane Marstons Mills ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Bob Thomps6n PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sclh' Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City state LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1 578 w CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system n this address and that the information reported is true , accurate, and complete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance - of on site sewage disposal systems . Check one : Systeoi PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public hea1Lh or Lhe environment as defined in 310 CMR 15. 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , XXXXXXXXXXXX System FAILEll* The inspection which I have con ted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 5/30/97 One copy of this certification must be provided to the OWNER the BUYER ( where applicable ) and the BOARD OP HEALTH. � • If the inspection FAILED, thv owner or`�4orator shall u d within one year or the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CFln 16 . 305 . artd .P doc = 3. - W U - Sb'jY �71 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFLED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June S. 1995 Acting Director of the - aon of Water Pollution Control � d v LOCATION o SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME & ADDRESS T r),KNrn w FFf f (ggLi�-NT 1) Z.. m10510Ns 013- B UILDE R OR OWNER P. 0 . 6c, ; 3_S6 W)USToNS rl� LLs DATE PERMIT ISSUED �a F DATE COMPLIANCE ISSUED �— Z� � `� �� _ _ _ i � � ., d' br � � ��\� �� � �, � .� � I � � � '�� � � vas 2 z `��_ �., ��� . 54 AJJ 3 !'c Ufi'l,0M �- ton CS Aln 5.4��yam-. lz J��It Q 4 d ' Porn Gfl Z 't r- p Cm /p. /J 0 0 r at/'7 `D/C f 7Z-76 7- 7/Z -77 5 G + 5� aY pOv l "uR44 y I z4-7 7 4 Yl L G%-1a"V t 0© r. 0ay .G Tap:CM-3 p d ape �NJ. Cg.ZS �•Z � � INV.�94,0 ��UGp Gill � I PeR!c i 4 OC• G A 4. o1T ..I a w/r C.t o•at tk•r*.,.� ° C-E1Z.T D PL(.t>-r R tOCATIC)" MARS 1 o M S HASS JA G CA L N_ qo ir-rLATi -7/z5 ?7 I CMVT1PY TN AT' T"C--rOVNDA-ctcN �1-1oo,c/dl Pt.-A1.! ���cRirt.lC� NEfZ6OW Ce,A.-XPLYG W 17 4 'i WE jl D'E-U W& 1_U T A► r-> SC-TVAr- C VGQUI9?Gkt;;-"TS ot= YN Tn W U o1= +BA 2E.�`tS�A[�t �,G>ct 13 PAGE z5' DATE 7 ZS ., L—f 6/S.kTEIZ t�.1YE t`.1G.. RGG{StttZL-D LA1�(r7 Su�v�Yo�S T141-5 VLAW {S "OT T:5A.•SC0 0t4 IM4 US'TE2Vtl-l.� v hr(aSS, k(-J,9 (JMt-tJT' -L0ZVM"{ 4 Ti{C Ca�"t'Si C-S >i1GWt APPL.IC_ !�!T' C��wr�F_T P�U� LD'`�'S t s1' gL- USLC> TO DCTi_R.WkJ LOY No.. y77..... Fs�. .. .Y.. ' THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH Appliratiun -fur Bi,ipu ial Works Towitrurtiun Prrniit Application is hereby-mn de for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal System at: Add or Lot No. ... Gill . . ...__ ....:. � ......( /1�� _ .--- --- f (� j��p 1 y p- ( 1n (/ WDi 'I3� �•� ._. Y.!l11M ---...------ J3ddrX/1s1_� 2..IX.Ik!.4/S-..1.Lrl� P Installer Address Q Type-,Of Building Size Lot............................Sq. feet a ','Dwelling—No. of Bedrooms---------- _-----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----•----------------------------•------•--------------------•------------------------------•-- _ g -0........�(..........gallons per person e day- Total d it flow.........��._........ W Desi n Flow.............. P P P Y Y • ------------gallons. WSeptic Tank—Liquid capacity`�Q_____gallons Length__-_-7...... Width........._.. Diameter................ Deptli..��...... x Disposal Trench—No- ---------------------Widt a... Total Length_.__.. Total leaching area_------__-_.-.____.sq. ft. Seepage Pit No..___1_QII0.... Diameter__.__ __ Depth b ' inle+_.6 ._ Total leaching area----._...........sq: it. Z Other Distribution box .( ) Dosing tan ( � `�- 77. Percolation Test Results Performed by .................. Date:'..__S_�2_�`.7- ......... a Test Pit No. 1----------------minutes per inch Dept of Test Pit--------------_..... Depth to ground water_-._-_..__-__.--.--_- �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--._..---___----_-.-. a ------------------- --- - ..................................... ........... 4— 2 Descriptton of Soil " .... ------ •-••-✓ ------- C _ C -r� yr _ �� ------�/ W UNature 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 Article NI of the State Sanitary Code—The undersigned furttier agrees not to place the system in operation until a Certificate of Compliance h een issu d by he rd of hea h. A Signe -- .--•- ...---- -- -•--.. -•--- • -•--------------•-- ................................ Date Application Approved BY---------- .. . --- i ------------- --_�•'�� -7-7----------- Date Application Disapproved for the following reasons:----••-----------------•- ................................................. -----------••--•----------••------••---•••----•----•---------------.......-------•------------•-•------------•---•••---- ... ................ Date PermitNo......................................................... Issued...................... ................................. Date _VA No......................... Finc..... . ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ..............OF...............................................1-1------- .................... INVptirattan -for Uiapoxial ip,arks Tomitrurtion Vanift Applicationj� hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ......... ---- -------------- -------------- -----------------------------------------------------• -------------------------------------------- - ---------------- or Lot No. Addr . ................................................................................................... .......... r.. ........... Owner Address .................................................................................................. ..............................................--------------------------------------------------- Installer Address U Type of Building Size Lot._._.......................Sq. feet Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons_-___--_---__-______.___-.-_ Showers Cafeteria ( ) GI Other fixtures ------------------------------------- ----------- ---------------------------------- --------------------------------------------------------- Design Flow------------------------------ --gallons 'per pet soli per day. Total daily flow------------------------I....................gallons. IY4 Septic Tank—Liquid capacity-------- ',.:gallons ..'Leng-th...... Width_- Diameter__-__.._ .___ Depth. Disposal Trench—No- -----------_------- Width--. __--_.*_ TotA'-terjgth..................:.*.',Total leaching area!---- -------------sq. ft. Seepage Pit No................... Diameter-------------------- Deptft Inije�- ------------ jotal leaphingarea------- ---------sq. ft. Other Distributibn box ( ) Dosing st t 77 Results Performed by_ .. .......... ................. Dater-----w---------------------------- 7�Percolation Test i No. I---------------Ininutes per inch ept of Test -Pit-------------------- Depth to ground water_--------------------- '�40 Test No. 2.........------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ V, ---------- -- ----- ------------".1........... -�..._..`- ........ 0 Kr � �/............ Descri of So;---------- - -- - ------ .... . ... ... . ------ .................... ----------- ------ ----------------- .......... --------------­--------------- --- - ---- ---- ...................................................................................... U ----?___f ----------- ------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable--------------------------------------- -:r--------------------------------------------------- - ----------- ----------------------- --------------------------------------------------------------------- - ------------ ----------------------------------------------------%�--- ------------ ft Agreef'henf:'*, The undersigned agrees,to install the afore'described Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanifiiry Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance s een iss b�the r of he th. Ii C 'j .,7Sign ..... .. .. ... ...... ----------- ................................ VApplicati6n Approved By........ ----- -- ---------------------- - -- - ----------- .. ------------ Date Application Disapproved for the following reasons:----------------------------------------........................-------------------------------------------- ....................................................... ---------------------------------------------------------------------------------------------------------------- ------------------------------- -.A, "' Date PermitNo. Issued----------------------..................................---------------— --------------7........ ...... Date THE COMMONWEALTH OF MASSACHUSETTS ,. B0 )F HEAL ! BOARD . ....... . . .................... .. ........................................-OF__.... ............... .. ... xf V T ks TO LjR� T tl}e Individual gewag Disposal System constructed or Repaired y...... ---------- ............... . ... ........ ..............��b -----------------------------------Y ------ ....................... ------------ .... .......�P�!- ------- in"ta,lier------- at------- 'e Sanitary has been installed in accordance with e provisions of rhAtal -'Lry Vide as described in the -L '.. "I-, ' X f ' 0 applicatiomfo'r Disposal,Works Construction Permit No______________� ;1 ', / ... ..7............. - ------------------- date d.........'-. J0 THE ISSUANCE-.OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY:' in� DATE..................................... � I .­. ......... ...................... ....... Inspector------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD �HEALT IY77 ..... OF....... .. .. ................ .... .................... ..... .. ... .... 77 N 0......................... R-riva or (IT a rtion Vamit Permission is hereby .... .. ----------------- Pe�mi -- - ---- �.�7- ewag o;s 'e ------------ - -- ------------------------------------------------to Consjr/V or R pa* n ivi, sp !,!'Ze *_. "4.' r Ij .. .. ...... V at No. ..A;r.................. -------- ----------------------0... ....... ............... ... ...... :k4--- - _- .. ............. Street -7 as shown on the application fq Works orks Construction it No.. --_ ated------- ......44..........7 ........... --- ............ - __ --,&-,V- ........................ Board of Health -----------------------­-­ ......................................... rrf FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -A L