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Home My WebLink About0530 ROUTE 149 - Health 149. 530 ROUTE149, MARSTONS MILLS t A= 079 032 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. City/Town 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 on the J I4— � �r computer, use 1. Inspector: �;/`� only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 Cityrrown State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certifythat 1 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ke�rw- 5/7/2009 Inspector's Signa ure 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. '1 /O t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. City/Town 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. CityrFown 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 El ® 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 '/day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. City/Town 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon sepyic tank,distribution box and leaching pit. Number of current residents: 2 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 Z No Water meter readings, if available (last 2 years usage(gpd)): 2007:40,000 2008:25,000 Detail: 2007:109 gpd 2008:68 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 5/7/2009 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 530 Route 149 Property Address John Tremblay Owner Owner's Name information is Marstons Mills Ma 02648 5/7/2009 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. Cityfrown 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 5" � Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 1011 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. Cityrrown 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 ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is Marstons Mills Ma 02648 5/7/2009 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 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 ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Water level was 38" below invert with no stain line above that point. 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments note condition of soil signs of hydraulic failure level of ondin condition of vegetation, ( 9 Y P 9, 9 , 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.): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 MaP Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® Zoom Outj I 111111,In \ is 1 L., I 1�. 1 i I I , I rr i 1 dl A. 1 I. I I vl lj I it (17 ZO..Feet, .... Set Scale 1" = 20 1 I Aerial Photos I MAP DISCLAIMER r..nmirinhf,)nng;_,)nnA Tn—n of Romefohle RAA All rinhfe meant, litttl-Nimnu tnxxrn Jinrn Qtnh1P. rnn ile/Ar(`.1mc/nnn(TPnnnn/mnn AQnv9nrnnprhiTT)=0'700Z700'IRrm ';i7ilnno Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 530 Route 149 Property Address John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. City/Town 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: Bottom of LP 60' 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: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data. USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 530 Route 149 Property Address P Y John Tremblay Owner Owner's Name information is required for Marstons Mills Ma 02648 5/7/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 CERTIFIED SEPTIC SYSTEM REPORT LOCATION 530 ROUTE 149 MARSTONS MILLS, MA 02648 MAP 079 PARCEL 032 002 LOT 14B PREPARED FOR SELLER MR LOUIS DIPACE 530 ROUTE 149 A^r "per MARSTONS MILLS, MA. 02648 q� RECEIVED BUYER �� MAY 3 1996 MR. '& MRS . JOHN H . TREMBLAY, JR. "" 37 HAWTHORNE CIRCLE PEABODY, MA 01960 9 PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 r Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection VAlUrn F.Weld Trudy Coxe �Y Garseror AMw Paul Cellucci Davld B.Struhs LL Goremor. C4Q1 wsiom SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A:. CERTIFICATION Property Address: 5'30 -'41/44S Address of Owner. Date of Inspeetidic- 1;tjr 1` ' (If differbpt) Name of Inspector. /-1/1-4,1,,9,20. H/GL•CI! Company Name,Address and Telephone Number. CERTIFICATION-STATEMENT 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 inspection. The inspection was perfbimed based on my training and'ex-peiienee in the-proper function and maintenance of on-site sewage disposal systems. The system: fgt* Passes _ Conditionally Passes Needs Furtlier Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this.inspection report to the Approving Authority within thirty(30)days of completing this inspection. Itthe system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Cha�,C,or D: AJ SYSTEM PASSES: t/I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15M3.. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or extiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One VAnter Street • Boston,Massachusetts 02108 • FAX(617) 556-1049 • Telephone(617)292-SM tJ Pnnted on Recycled Paper . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S'2 d .,M /</f� 7-,1WS To,—� Owner. T Dante of Inspection: c�/asJ96 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more^than four 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 obstruction is removed Cl 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) SYSTEM WILL.FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT% The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well,water analysis for oolifo;m bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. 3) OTHER (revised 11/03/95) 2 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: A�j 'etIz_4' Owner. fly pills T t9//' G� Date of Inspection: 7/�s/gam DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. -The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility_or system component due to an overloaded or dogged SAS-or cesspool: =^ y' Discharge or ponding of effluent to-the surface of the ground or surface waters due to-an overloaded or clogged SAS or Cesspool. t Static�liquid level in the distnbution,box.above^outletdnvert due to as overloaded or clogged SAS or cesspool. Liquid-depth in cesspool is••less than 6",'below invert or available volume•is.less than 1/2 day.flow... .. ,..- Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is-less,than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public beelth and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program rrquirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information._ (revised 11/03/95) 3 l_ I fl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CHECKLIST Property Addrew 53v 4vv,-4 lY9 Owner. 4-11,1 L av_/f cJ, l7i oitc,� Dale-of Inspsotion:' 'Chsclr if the following have-been done :,,-.. . Pumping information was requested.of the owner, occupant, and Board-.of Health. None of the system components have been pumped for at least two weeks and.the system has been receiving normal flow rates during that period.. Large.volumes of water_have not been,introduced,into the system recently or as.part of this inspection. _As built plans have:been obtained read examined. Note if they:are not.available with N/A. _The facility or dwelling,.was inspected for-signs of sewage back-up. _The system does not receive non-sanitary or industrial waste flow _The site was inspected for signs of breakout. _All system components,excluding the Soil Absorption System, have been located on the site. _The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of$cum. _The size and location of the.Soil Absorption System on the site has been determined based.on existing information or appraaimated by non-intrusive methods. _The facility owner(and oocupants;if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `i5 t�r . .,..s1 'PART.C ' . SYSTEM INFORMATION Property Andress ,43e, Owner. lylai . Lov�S J� O/�laGF Date of Inspection: FLOW CONDITIONS RESIDENTIAL - Design flow' 3 ,2 ns Number of bedrooms:�� Number of current residents: a : . Garbage grinder(yes or.no): yam: < .b;z r�,�:. 0 Laundry connected to or no): �.��system(yes w. Seasonal use(yes Water meter readings,if available Last date of occnpancy:_6 f 9x- -y COMMERCIALANDUSTRIAL- Type of establishment- Design--flow: Vallons/day. - } Grease trap present:(yes.or.no)_. Industrial.Waste;Holding,.Tank_ resent•p . (y es orno)._ _ •.,: ,y .. ; - �,.;.,.... __ ._._. _ Non4manitary waste:discharged to the.Title 5 system:.(yes or no)_.. Water meter.readings,.if.available: Last date of occupancy: OTHER(Describe) Last date-of oearpancy: GENERAL INFORMATION PUMPING.RECORDS and source of information: System pumped as part of inspection: (yes or no)YES If yes,volume'pumped:LYeatgallons Resson for pumping: LXf kz yG TYPE OF SYSTEM _1LSrptic Ltal�/distnbutma boa/soil absorption system Single ossspool Overflow cesspool Privy Shard.system(yes or no) (if yes,attach previous inspection records, if any) Other(aplain) APPROM31ATE AGE of all components,date installed(if.known)and source of information: gaw-Cm odors.deteeted,when arriving at the site: (yes or no) (revised:11103195) 5 i".;J f.e'+t�i_�`°'' SUBSURFACE SEWAGE DISPOSAL`..SYSTEM INSPECTION FORM .:.ci `.PART:C<c SYSTEM INFORMATION (continued) Property Address: 5,30 X74 /y9 h s7ays " Owner. /i .y. L�vls Date of Insp/eetion: ✓, d/.o - Is TAN1K:� (loc me on site.plan) Dept ](stsrial.of,comstzvction:�sonerete•_metal_FItP__other(ezplain) _.. . Dimsasioas flhAr dpthDistance from top of sludge to m'.of cutlet-tee.or baffle: &um thidmess Distance f mm.top of scum to top of outlet tee,or baffle: Distanos from bottom of scum to bottom of outlet tee or baffle: / — - - �'•'- - -,. ''''`i (recommendation for pumping, condition.of inlet:and outlet teen or baffles, depth.of liquid level in relation to outlet invert structural into ' evidence of leakage,etc.) 7'AA W Ge--IAC LAK4,t t/(r / /S`' o% /4'v/D f},B�O G.G�d'�yoZ iOy..�i°lO Pity, �� GvGGl� THd 4�.e l GE T E 7,1E£S Lvov l 0 .�PPcv,�i�iCvv }Y. GREASE (locate on.site.p Depth below grade: Material of construction:_concrete_metal FRP_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet.tee or baffle: Distance from bottom of scum to bottom of outlet tee:or baffle: Comments: (rsoommendatica 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.) (revised;11/03/95) 6 SUBSURFACE SEWAGE.;DISPOSAL SYSTEM INSPECTION FORM PART Ct. ,r > SYSTEM INFORMATION (continued) Property Address: S30 IeTL /yy .ts Owner. L Date of Inspection: . .. ..,,.girds.:: rr.'-�..1.'� ��i.-.;,. .. -._"-i r .. �:.°"� ru'. ,.-�i:�.i�': ..:�"r�"'• .�.mot: .:k,}$ + r. w�..�G.,> TIGHT OR HOLDINGTANK� (locate on site plan) Material.of ooastruction: coacete_metal -FRP othehezplein) Dimensions: Capacity: n1lona Design flow: aalloWday ....v. _ Alarm level: Comments: _ s < �,E• °ti _z a s•. ,r (condition of inlet tee,`condition of alarm and float awitches,_etc.) y ^y DISTRIBUTION BOX:!/ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of 1 into or out of box,etc.) GoX L�o G�I�D 7 4' L IQe-1/12 4i/�s L�� t3cil C�Y l dt�Si �i/�i i�� A•tV/� /G1y/D L G!/�L /.!/ Ti'7'� .6/ L✓Gl/LO !� T/Ya�f>HT PUMP CHAMBER: (locos on site plan) Pumps in working order-(yes or no) . Comment.: (note oondition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 I • SUBSURFACE SEWAGE DISPOSAL SYST'EM_IN9PECTION FORM PAST C - SYSTEM INFORMATION(continued) Property Aadre.c Owner. -*10t, Date of Inspection: y/d 8. 3± BOIL ABSORPTION SYSTEM (SAS):1� Qoeate on site-plan,.if possible;excavation not required,but maybe approximated.by non-intrusive methods) If not determined>to..be praeent,explain: Type SP +;'number: ; lseeking chambers,number— keeling:galleries,number: _ __ .. ,.; •f leaching trenches,number,length: leeching fields,number,dimensions: overibw cesspoo number: ._. Comments:(note condition of soil, signs of hydraulic failure, level of.ponding; condition of vegetation etc.) ,(l0 S/G,(i �� CESSPOOLS: (locate on site plan) Number and-configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum. ayer Dimensions of cesspool: Materials of construction: Indication of groundwater inibw(cesspool must.be-pumped as part of inspection) Comments:(note oomditian of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRM. (locate an site plan) Materials of coasts Xtion: Dimensions: Depth of solids: Commants:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) (reirised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Addrew- SgU a%� /y-y �rnsT this �►rG G s Owner. Date of Inspection: SIiKMH OF SEWAGE DISPOSAL SYSTEM inch ties to at Last two permanent.references-landmarks or benchmarks locate au.6 i within 100' - yy �•• DEPTH TO GROUNDWATER Depth to po mdwater. /7/'t"-feet ssothod of demon or approximation: /9%�oLE 7.5-/. -T 6'r e2L6L!r10 o G�� Ti7rsL.� i£ /9S� d•�?f/ /; G �!��rvs T %9 -,Z O GS 3 7&/- moo-, 7/-.YA' /e/r /S 9'�OEG/J 75 -,351 -y 3 /7 7 (revised,1.1/03M) 9 i 79 Z50�,7 NO ................ Fmc;l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............FOU).0........OF.....:1L5&;.JeDM.L, Appliradivit for Mqpviial W,arks Towitrurtion ramit Application is hereby,made for a Permit to Construct ( VI-111or Repair an Individual Sewage Disposal System at: - � ------- ..................lar--148 .. ................ oWAddress or Lot No. ................................................ .................................................................................................. Address �.....aw ................ . ...................................................... Installer Address Type of Building Size Lot__I AJ6------ 41mt Dwelling—No. of Bedrooms___-_.--_--- ______________________Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ...................................................................................................................................................... Design Flow...................55.................gallons per person per day. Total daily flow.........................3.3.0.....gallons. Septic Tank—Liquid capacitylOM.gallons Length................ Width._............._ Diameter-______--___-___ Depth............._.. Disposal Trench—No..................... Width_....__......__.__.. Total Length.._._............... Total leaching area....................sq. ft. Seepage Pit No---------i-------_,Dianieter.......1.Q...... Depth below inlet.._...._....... Total leaching area.....2j(d.&..sq. ft. Z Other Distribution box Dosin&ea ( ) 0-4 _ '.*��:� — -z - - 3 Date...._._ . Percolation Test Result, Performed by._. ............................ ... .. . ......... �--j z�..... .Test Pit No. 1................minutes per inch Depth of Test Pit....... Depth to ground water......_____...__....___. ............ Test Pit No. 2................minutes per inch Depth of Test Pit..._._......_...._.. Depth to ground water_.__._..............____ 1:4 . .. . ...................oe............................................................................................................ ------------------- ------- 0 Description of Soil..........0,:4...... . -_... ......................................................................................... U�4 ............................................ — ILI 4 44--- 10- ------------ --------------------------- ---------------- ..............................................................................................................................I------_------1__11.................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .....................................................................................................................................I.................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersign o furthpr agrees not to place the system in operation 0un-- ti .va rtificate of Compliance --- --asp..p.. .. issued y th.e. a.i..d. oy/hkealth. Signed ........ ... .. ...... .................Date -. -- -- -------------- ApplicationApproved --------------- -- -------- --------- ....... .......... ................................................ Date Application Disapproved for the following reasonf: ...................................................................................................................................... -------------------------------------------------------------------------------------I.............................................. .......................-------------.---.--------------------........... ........................................ r Date Permit No. .... cz....../21�_er------------- Issued ........ �Date 64, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ %M W........0F...` �/!2: 1 > � ,, c.= Appliration for Disposal Warkii Tnnitrnr#iun amit Application is hereby made for a Permit to Construct ( :f)�r Repair ( ) an Individual Sewage Disposal System at: ... J ......................�c.......Address------------------------------------ .................................................. Lot.No..........._.............................. M............................................... ...••-••-•-----............................. •----•-•--.................................--- Address Installer Address d Type of Building Size Lot..._"_. __..�.1 e:.....SI—fret U Dwelling—No. of Bedrooms...............8..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons---------------------------- Showers — Cafeteria QIOther fixtures ...................................................... - -------••.....•••---- W Design Flow....................'3.S ----- ...-............_gallons per person per day. Total daily flow____.._..................6....0......gallons. WSeptic Tank—Liquid*capacity.112 .gallons Length................ Width................ Diameter................ Depth....._.......... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------L.......... Diameter.......W...... Depth below inlet........?........ Total leaching area......4K--?4?.sq. ft. Z Other Distribution box ( tf)" Dosing-tank ( ) _ Percolation Test Results Performed by___...'��.'_t(_1s)? _ v ..___ -............... Date___.....; - _9.."_93.__.- ,`�j Test Pit No. I....../......minutes per inch Depth of Test Pit....... �*...... Depth to ground water-------- ............. (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �.y ........... r..... ...................P .._.__._.._........_._____________......_......._._...._._._.................._._.....__.___.._..____.._._. O Description of Soil..........D_:-A......�:6!� __ `_.__ ?v � '._E-- ---------------------------------------------------------------------------•------------- x -----------................................ _.�.. � �� ; ..., ;; ......§A-44-0- -------------6rfi-AVXZ- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a-Certificate of Compliance has been issued by the board of health. � { �t /'� --�;- Signed ------------------------------------------------------------------------------------------------------------ ---------------------------------------- Application Approved By ............... /i�9� ,,.�_ ".. --- -. .. r----- <' ' Date Application Disapproved for the following reasons: ------------------------------------------------------- —.......................................+^.................--..-. ........ ............................Date Permit No. / I/...--`-•,�. ... ...--... " ---....---- Issued �, .............:........Dates------......... .....-�,...:..— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --------------- c m.�.-------- OF ........ I",T-A 3_Z Certificate of C�omlatiance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by------------------------------------------------------- ------------------------------------------------------lle-----------------------------------------------------------------------......--------.....------------------------------- • Installer at - '" � '� ..l3t�` � �1 !I i�1 t � .... -/-r-r.- ?...........................*------------------------------------------------------------------------------ ---... has been installed in accordance with the provisions of TITLE-,5,of The State Environmental Code as described in _ the application for Disposal Works Construction Permit No. .......�.. r--.-... ,� _ '--.. dated ., .. ...... -' PP P r..,/� s THE ISSUANCE OF THIS CERTIFICATE SHALL NOTrBE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................+ ^ Ll- ---------..........--------------------------------- Inspector ---.-------- ...e ms ................................................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD; OF HEALTH ...`..r /-� FEE;:...'...........r Disposal,Works 0141ma ion rrmi# Permission is hereby granted -` t-j .......e:.--�---------------•---------------------------------------------------•-------------------•-•--....... to Construct (�or Repair ) an Individual Sev�>age Disposal System at No.--------- .....i S 177:o......(��1_. �i/��-��Ga`�L?�`i t Street ^V as shown on the application for Disposal Works Construction Permit No:.`l'�f....._ _%.Dated...±. �_`.._:�%%'' � .........---•--•--------•---------------------------------------------------------------------•••------- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS s1 1 FAA J,' ,u T f � SEAlC`PAI TAt 3 x 15o Qq5 dP�,, T ' I000 �At, BpTTD�VI rcTfAL U_516N ._ u spy,: OzmT s hi lula 47CTAt_.. VA!LY. PE2G a LA-M oN..`2A-rF .�''in12 i1^y j l(,ASS R' PP 7TE1R s t RARD SULLIVAN i u fdo. I-�733 : <• ` /.'. �M+�. �w',� a�.�l"'0�ila"�,- it 4 T IN✓, qG g Qu✓. �GArr TAR G�A�L� V_ s `�'� 5r�ucruQEs; sir sTo MME,T1 W.. 4'v aE AAF PCL 3r�•'Z_ ZONE �F — y�lapPOLI,(Lr . 1 -��. 1_G=a �aGl�E I IL r,' DATr=- V ol!t 1� C EJZTI F`��:.T�-I kT'''('t.j� iJiv cl�Gi.►J L "' ' _... � 5(�DW NE2ECh1, CoNI'PtyS 5v17'A TEI �jldEU4f LpT 14-II 2e4);.:OP.. 'C IE-. U4 off; RArz4I57TXPZ�lG . gtD :15 to�,4 'D l t�: T�kZaav; t.oi�t 15 .- FLAQ (S Not' ?Alie> : C�( tiN 1�15'TL?vktE+JT' ck.i I L EiJGi N LErL.s UPVC- AIJt� rH �FFSeT'S ._� flutes uScn T'o ESTQBL(si-� Et�Ty . WC APPLlcA�t7-- ' r.. t7U1 P ICI "D l —;. ,i Y 5►� `�- 2 OF / Lvw 5 FFkrwe�a DiP�ar- c� \� Asa `_. — ��ed9& �(oo z Id sa P TT , 14 �' aW w OF it }. ' A .a p .3tAXTER WoPC A-1 C . x JA kn 7 q pe- '32-• Z TOWN OF BARNSTABLE L0CATICG�r �30 X71 /hf SEWAGE # V LLAG 1,41V 5,Th� /'/L4 S ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /mod 61f Z- LEACHING FACILITY: (type) (size) eons NO.OF BEDROOMS 3 B�OR OWNER PERMIT DATE: 3 Z511 3 COMPLIANCE DATE: 3 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 �-nk 3a 7y gq'11n� �= I I r' G TOWN OF BARNSTABLE L� Nam, ✓A LGCATION L-O'T ��U 149 SEWAGE # 93- lq6 VILLAGE M. '�`'�_` > ASSESSOR'S MAP & LOTOfn-O3Z. Z INSTALLER'S NAME & PHONE NO. K\e. C4t4� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Q I� (size) f . � NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER BUILDS OR OWNER DATE PERMIT ISSUED: 3 g DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �/ t.a. a, • .. •s ^`� 4 G T I, '. ,. �� J�/ ��,1 1 �� , . �P� u� ��'� 5'7 `