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HomeMy WebLinkAbout0401 ROUTE 149 - Health I401 Rte' 149 Marstons Mills A = 079,=01.1 - YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: / Fill in please: r � APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADDRESS: i S e%F-7z-r-4qs'aIS. TELEPHONE # Home Telephone Number -7 Sa.S NAME OF CORPORATION:.: .: LAue S Re,r.b,)1,, NAME OF NEW BUSINESS TYPE OF BUSINESS. 421 C:ell IS THIS2 AlHOME OCCUPATION? YES NO ADDRESS OF BU/S/INESS.`�v i Co usr� .12d..� ; 15': ;� :MAP/PARCEL NUMBER. ` � o.:I (Assessing)', When starting a1n w business ess thearn sever t�hing�ou must do in drder t en o npliance with the rules and regulations 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 your business in this town. f�. 1. BUILDING COM'VIISSIO R'S OF CE � This individual h n iRfQr o ran�er it requirements that pertain to this type of business. MUST 1. COMPLY WITH HOME OCCUPATION r� Au horizg Signature,*'* RULES AND REGULATIONS. FAILURE TO COMMENTl rnmpiv a4AY RE-91�11=T- n6A)A 2. BOARD O EALTH This individual ha n informed of ,permit r ui ments that pertain to this type of business. uthorized Signatur COMMENT 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 I t1 { t�=, 7 i ._ t 1 } S R Mom' 4K n :y� — — p I A ; a f CAI 1 . � : � � s ; -F � � � a' � � a _ �� ,� ?� � I � � � .. \ � � � \ - .. �. Y � - - � �� � �' AsBuilt Page 1 of 1 ' TOWN OF BARNSTABLE LOCATION, C�T:�T `'S1� SEWAGE # U�^ R VILLAGE ,Sbw w I 1# S SESSOR'S AP & LOT 07 INSTALLER'S NAME.Sz PHONE NO, Gr3��, SEPTIC TANK CAPACITY j8©n LEACHING FACILITY:(type) /d Q a (size)_ NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 1-9 t, BUILDER OR OWNER DATE PERMIT ISSUED: 1� DATE COMPLIANCE ISSUED: )�.-�/- Y VARIANCE GRANTED: Yes No ✓ httn //iccrill/intranat/-nrnnrlata/nralinilt acnv9mAnnar=0'7Q01 1 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owners Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown 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 end of the form. Important: A. General Information When filling out forms the computer, r,use 1. Inspector: U only the tab key to move your Ricky L.Wright cursor-do not Name of Inspector use the return key. B& B Excavation, Inc. Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number B. 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspectors 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 10,000 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. V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. City/Town 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: ® 1 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): f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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)that the 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown State 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 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 cesspool is less than 6" below invert or available volume is less than '/2 day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons&Patricia Souza-Lyons Owner owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown 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 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 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 II 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. TOWN OF BARNSTABLE ' LOCATION , — = sy SEWAGE # 7� VILLAGE M p rStyv✓ (4i SESSOR'S AP & LOT OQ�all INSTALLER'S NAME & PHONE NO. a e'� ew�.• +' SEPTIC TANK CAPACITY JQ00 r LEACHING FACILITY:(type) (size)_ NO..OF BEDROOMS .3 PRIVATE WELL OR PUBLIC WATER �O��Lfl fr S BUILDER OR OWNER '0' L*&> � � OQ DATE PERMIT ISSUED: I Q a h DATE COMPLIANCE ISSUED: ,, )�.-�1- $ry VARIANCE GRANTED: Yes No 1� .� e • �� � � � �6 �!°� -_a Town of Barnstable Health Inspector F Hours VE T Regulatory Services Office g y 9:30 8:30— :30 of Thomas F. Geiler,Director 3:30—4:30 BARNSPABLE, # Public Health Division MASS. 1G39. Thomas McKean,Director �pTEli MP'I A 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE March lgaq Date:March 1,2010 M4 rGh l b�?hk 1. General Information: Size of Property: 0.75 acre Address: 401 ROUTE 149 MARSTONS MILLS' MA 02648 Map 079 Parcel 011 Name: Michael Mayne and Barbara Mayne Phone#: 508-737-2422 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms? NO If yes,how many? 0 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 3 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open.doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO ,r If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? tsp a C) Y+—G AI 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? - YES or t NO =` 8. If yes,how many bedrooms were approved according to this permit? Bedr�oms. ~;= sv e 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11.-Has the septic system been inspected,by a DEP certified inspector within the last two years? YES or NO --------------------------------------------=---------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyappl.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown State Zip Code Date of Inspection 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 N/A) ❑ ® 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): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 O� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M "r 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: October 2009 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/persons/sq.ft., 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: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11110 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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/Alternative 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 33"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >20' feet Comments(on condition of joints, venting, evidence of leakage, etc.): at time of inspection building sewer appears to be in good shape Septic Tank(locate on site plan): Depth below grade: 36"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: 5.5'X 5.5'X 8.5' Sludge depth: 3" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11110 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): at time of inspection tank appeared structurally sound -is and baffles were present 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 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,• 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner owner's Name information ormaton is required for Marstons Mills MA 02648 2/11/10 r every page. CityrTown State zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels 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 0 No Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2111/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert n/a 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.): + II Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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 ondin , dam soil, condition of ( 9 Y p 9 P vegetation, etc.): at time of inspection no hydraulic failure-no signs of backup and no water in pit 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every page. Cityrrown 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is Marstons Mills MA 02648 2/11/10 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Al - 39 81 . 13' AZ- 39'a" t32. 19 , A3- 49 ,B 3• SG Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 401 Route 149 Property Address Daniel Lyons& Patricia Souza-Lyons Owner Owner's Name information is required for Marstons Mills MA 02648 2/11/10 every 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: 35' 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: 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: per local engineer You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. Town of Barnstable Health Inspector Office Hours FtME roy, Regulatory Services 8:30-9:30 Thomas F.Geiler,Director 3:30—4:30 BARNSTABLE. * Public Health Division MASS. 1639.� ♦44 prEn s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fa : 508-790M6304 p AMNESTY PROGRAM APPLICANT = SEPTIC QUESTIOl1AIRE Date: arch2010 L tv 1. General Information: Size of Property: 0.75 acre —t Address:401 ROUTE 149 MARSTONS MILLS MA 02648 Map 079 Parcel 01 hJ rn Name: Michael Mayne and Barbara Mayne Phone#: 508-737-2422 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms? NO If yes,how many? 0 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 3 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ----------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyappl.DOC tory DL V ` IS J � � .�,�„ � ►fin ��� e VO/ OL s nd� r=/00 FORM 30 � �� HOBBSS WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN w �A iNk-7 DEPARTMENT AkDRESS 4�M sv0y`er ( �V F2) //,, __ C�/�; TELEPHONE Address ` io ( "ar- 14A �"� P tftccupantAN6�� �'�1 DNS Floor Apartment No. • No.of Occupants No. of Habitable Rooms ` No.Sleeping Rooms No.dwelling or rooming units-2- No.Stories Name and address of owner ck3_s.0 \� r� (� t v—m LA I Remarks Reg. Vio. YARD Out BI s.: Fences: Garbage and Rubbish (' Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.. ❑ B ❑ F ❑ M Doors,Windows: Roof 1- ' / Gutters, Drains: V Walls: N ^ LAW A i%&-% XN-[ Foundation: Chimney \ Z 15 c c-0 Ir BASEMENT Gen.Sanitation.- Dampness: -T\A ¢ik Stairs: Li htin : 96Kvi 'L STRUCTURE INT. Hall,Stairway: Obst'n.: 'j - p. &-a:1 Hall, Floor,Wall,Ceiling-, Hall Lighting: U . 1,\4:'C Hall Windows: HEATING Chimneys: (Z_ �. l.. Central ❑ Y N Equip. Repair TYPE: - Stacks, Flues,Vents: L: PLUMBING: STPPIy Line: - ❑ MS ❑ ST- P Waste Line: H.W.Tanks Safety and Vent(s) E915CTRICAL 41 Panels, Meters,Cir.: \ 0 *...3 It 110 ❑ 220 ' Fusing,Grnd.: AMP: Gen.Cond. Distrib. Bo : Gen. Basement Wiring: DWELLING NIT Q Ventil. L to . Outlets Walls Ceils. Wind. oor Kitchen Bathroom Pantry Den Living Room Bedroom 1 . Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink 0-;4�4-t V LU t34CJ_A \ N V Stove N !s T Ly Q� b F- Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: -c 0,j I£ Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Ejuilding Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES PERJUF� .." INSPECTOR TITLE A. . DATE ! TIME 'w0 C) p A.M. THE NEXT SCHEDULED REINSPECTION I\ J /'Ak P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety when found t exist in residential remises shall be deemed conditions which may endanger or The following conditions, e ou d o Y 9 9P impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410,250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR'410.480(D). (1) Failure to comply with,any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone-else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of 9Y accep ted ted plumbing, heating, gasfitting, or electrical wiring stancards that do not create an immediate hazard. P 4 Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. 1�South Shore Community Action Council,Inc. 265 South Meadow Road to 17 Plymouth,MA 02360 ` F A lication#: 82907 TO: DONALD G LYONSM PP 401 COTUIT RD Notice Date: 9/5/2008 MARSTONS MILLS,MA 02648 Application Date: 8/4/2008 IMPORTANT!!! • This letter is to inform you about the action being taken on your 2008-2009 Fuel Assistance application. Your applic ation is INCOMPLETE.We cannot help you with an oil delivery,utility payment or rental payment or call your heating company without the following information: The following information is requested for DONALD LYONS. Rental Income Please Submit the following: Copy of your most recent Federal tax return form 1040 and Schedule E complete with signatures.The forms must be signed by a certified accountant or tax preparer or notarized if self prepared. Or Copies of rent receipts to tenants for the last month or copies current lease(s)or statements from tenants as to amount and frequency of rent.You may also submit the following documents for deductions: Copies of annual property tax bill,water/sewer bill,house insurance and mortgage interest. Thank you for submitting previously requested documentation for MARY LYONS as follows: Interest/Dividend Income(The first$100 in annual interest will not be counted)On 9/2/2008 ADDITIONAL COMMENTS PLEASE PROVIDE COPY OF 2007 FEDERAL TAXES IMPORTANT! YOU MUST COMPLETE YOUR APPLICATION BY 5/31/2009 WE CANNOT GUARANTEE AVAILABILITY OF FUNDS IF YOU DELAY SENDING IN THE DOCUMENTS IF YOUR APPLICATION IS INCOMPLETE ON 5/31/2009 YOU WILL BE DENIED. If you need help getting this missing information,please call us immediately at(508)746-6707! ESTA CARTA ES IMPORTANTE! POR FAVOR TRASDUSCALA IMEDIANTAMENTE! r (ommum4y JoLAS&x A Je-F f,vi, c� m��� i s � v 10 �� e� bey� r-��e� nod safe, vq� -Tkc O�ewA rn.ull w , I 1 fie. o5�� by Mov� d- )oncdo� Lloos oS G` be&rwovx �v� l� ���� ( oou,� . �(if� �.y�vS i5 ha✓��iCct�Pe� u��l CCtnnq� use- ib 4v-e.. �ewAk -Float )D-J-roWyQ� bt llwvl� S M CQ Entries Saratoga, August 23, 2008 Daily Racing Form Page 8 of 8 f { P t i �I k !I f 1 C I I . 5 _ E 9\ - 1 http://www.dr£com/entries/23/eSAR23.html?rn=419795 8/23/2008 ��'1Dysrr,"'.�. z_t'.p. y�.�r, -.yr.�,,...:'..+r—_w�<,o.yT NyW�,y� E:i•�' .�,¢,e, 4,�r�?tr"'I''� ''''f y.y .'" ,�' *�,,y+ -,'. '-tis„"t...p Tr' ,�" �' e�" .' +"1'�.�r`�' ,�...-�:�t%�4.h'Fr r^ii::#1_.+M fi,.+3-r, '�yo�'q.�'y�� +r`a �^'U,,v:'*•er,^., rr � 2 FORM 30 <Ht&W HORRS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH CITY/TOWN a DEPARTMENT ADDRESS I I I t G'+M 5V0\`0 .k © TELEPHONE Address `""it?( K0_j2 lint '' ' i11414LOccupant� Floor «+ Apartment No. i TA No. of Occupants ..u No. of Habitable,Roo T___2.._ No.Sleeping Rooms No. dwelling or rooming units No.Stories Name and address of owner .,..ALYD 11 . t �" it (0 1 � 3 tl , 1,4A . lC° +w'�"7t?+64 I ( - I � � ,� Remarks Reg. Vio. YARD Out BI s.: Fences.- Garbage and Rubbish ',,Containers;, r Drama e ,+ -- Infestation Rats or other: ` STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n: y.r- ❑ B ❑ F ❑ M Doors,Windows: IfY Roof '' �{ ; " '• t-'11s Gutters, Drains: Walls: .. W — LAW tN«oNd--%-A "_n,xT Foundation:--''' rt Chimney: e �� r r"b e-*5 C c(.,A t BASEMENT Gen.Sanitation: 9 Dampness: i fl, \-f a t.-AsL 6 '".4 Ki� Stairs: y� Li htin : V Ltn►F»J r. STRUCTURE INT. Hall,Stairway: f Obst'n.: ",,� � � l�.!)N Z 1 vA15 --ru Z Hall, Floor,Wall,Ceilln : Hall Lighting: t % . I'me-4 f`,.)%,,j z:T r-A,; Hall Windows: w ! HEATING I J Chimneys: :J( 'C""& t.-r1 A Centr.,al ❑ Y f❑ N Equip. Repair ' .Stacks, Flues,Vents: '»t 71z r_ c ,cit, �. - - - PLUMBING:- > '=-'Su I Line ❑ MS ❑ ST [I P. Waste Line. A _ rt , , /r H.W.Tanks Safety and Vent(s) L COT Panels, Meters,Cir.: Z Ca w !+� P. L I COT ❑ 220 's Fusing,Grnd.: f , z AMP: Gen. Cond. Distrib. Bo : Gen. Basement Wirin DWELLI'NGVNIT Ventil. L to . Outlets Walls Ceils. Wind. tlboors--Floo`r'$7:n(cks Kitchen Bathroom Pantry Den -� Living Room Bedroom 1 , Bedroom 2 r Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink le 6�4%(,r ,-�Z - �v 4) t.0 1,4G NJ W y ,. Stove tr , vt o, s Z u e t.o na Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: v Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: j General Building Posted i,1''Locks on Doors: ` ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES F PERJURY." INSPECTOR _.-.> _ TITLE A.M. • !/ . DATE P:M' � � �-7r�2�JF�� TIME r` � A.M. THE NEXT SCHEDULED REINSPECTION K P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation,any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. r I AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION- �� c�T.�T /~'sue SEWAGE # VILLAGE_MA S N1i�15 SESSOR'S AP LOT 0"i . INSTALLER'S NAME & PHONE NO. CirJ�:� SEPTIC TANK CAPACITY 16 0n LEACHING FACILITY:(t"ype) /d Q 1) (size)�� NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATEE BUILDER OR OWNER e Lq pr4s DATE PERMIT ISSUED: I v2 DATE COMPLIANCE ISSUED: ,�a. -C/- �Y VARIANCE GRANTED: Yes No �r 1 DecK. �6 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=079011&seq=1 3/2/2010 oFVWE T� Town of Barnstable Barnstable Regulatory Services Department M�Amaisa j } BARNSPABLE, O D y MASS. 039. Public Health Division MA+A, 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 r Thomas F.Geiler,Director t%' FAX: 508-790-6304 1 Thomas A.McKean,CHO South Shore Community Action Council Inc. 265 South Meadow Road Plymouth. MA 02360 September 29, 2008 RE: Donald G. Lyons 401 Cotuit Road, Marstons Mills, MA 02648 Dear Sir/Madam At the request of Mr. Lyons I inspected the property at 401 Cotuit Road, Marstons Mills, MA to inspect the portion of the dwelling that was formerly used as an in-law apartment or rental unit. As of 10:00 am on September 25, 2008 the stove and refrigerator had been removed from the rental unit and at this time the area in question is not being occupied as a rental. Mr. Lyons has stated that he plans to convert the area that had been used as a rental to living quarters for his family as health reasons have caused a need for a first floor bedroom. Please contact me if I can provide you with any additional information concerning this matter. iim rds, e Cabot h Inspector Public Health Division Town of Barnstable cc: Donald G. Lyons Page 1 of 1 to TOW `t;1YP BARNSTABLE 'LOCATION -V,dl j ��11� SEWAGE # 3 72, VILLAGE��rSw �1f'115 SESSOR'S AP LOT G'7 / /� D/ L \ INSTALLER'S NAME & PHONE NO. Q114 G1Ja.�•6r SEPTIC TANK CAPACITY 1_6 r LEACHING FACILITY:(me) J d 0 D (size) L NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER Lr, w �r BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED:` f I C/- li�Y VARIANCE GRANTED: Yes No I L i i r! - a/prebuilt.aspx?mappar=079011&seq=1 2/10/2010