HomeMy WebLinkAbout2415 MEETINGHOUSE WAY/RTE 149 - Health 241Y5-Meeting:House Road
Vest,Barnstable
rA=Tl 55=0 f8-AO 1
Town of Barnstable
Inspectional Services
S�' Public Health Division
a° 039. 10
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Fax: 508-790-6304 Office: 508-862-4644
AFFADAVIT FOR A BED AND BREAKFAST
PERMIT EXEMPTION FORM
r
Name of Bed and Breakfast: L 6 �1��� `k'� ��>2-`'-"���z
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Address:
Telephone: zerAl �—
Name of Owner: (�
Telephone Number: ,
As Per 2013 Food Code, State Sanitary Code MA Regulations for Minimum Standards
for Food Establishment, Chapter X- 105 CMR 590.001 (C)(1) and can be found on
website: https://www.mass.gov/regulations/105-CMR-59000-state-sanitary-code-
chapter-x-minimum-sanitation-standards-for-food
I attest I am qualified for a Bed and Breakfast Permit Exemption because I meet the
foil wing criteria:
❑ bwner Occupied
�01/Available guest bedrooms does not exceed 6
J Number of guests does not exceed 18
,
a Breakfast is the only meal offered
The owner/operator is responsible for ensuring all consumers of this establishment
are informed by statements contained in the published advertisements, mailed
brochures, and placards posted at the registration area that the food is prepared in
a kitchen that is NOT.REGULATED/NOR INSPECTED by the FC-regulatory
authority.
Signature of Applicant:
Date:
Q:\Application Forms\Bed and Breakfast Exempt 2019.doc
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APPLICATION FOR SITE PLAN REVIEW Sp#
Date
LOCATION
Business Name:. � �` '� Subdivision Plan
Assessor's Map.# /_s5- cel# O/ f ANR Plan
Property Address: . (,c ee Site Plan
2G 4V
OAR OF PROPERTY APPLICANT e"
Name: /j 13 G"�G ��C bv1AL- Name:
Address: Address: 61
��S
Telephone: ��a e Z, +�c 9S Telephone: trd i G�-
Fax Fax: -S
ARCMTECT/DE•VELOPER/CONTRACTOR/ENGINEER AGENT/ATTORNEY
Name: Name:
Address: fir-n, - C-�-- Address:
Telephone: Telephone:
Fax: Fax:
STORAGE TANKS(HAZ MATNM OR WASTE OIL) ZONING DISTRICT CLASSIFICATION
Existing Proposed District 1 Overlays)
Number Number Lot Area Sq.Ft. Ac.
Size Size Fire District
Above Ground . Above.Ground
Underground Underground Setbacks ft.
Contents Contents Front: Side: Rear.
Number of Buildings
Existing Proposed
UTII.ITIES Demolition
Sewer ❑ Public Private Size%ed gal
Water ❑ Public ❑ Private r TOTAL FLOOR AREA BY USE
Electric ❑ 4erial ❑ Underground Existing Proposed
Gas V�/Natural ❑ Propane (sq.ft. . s ,ft.
Grease Trap ❑Size— gal Basement
�l�Sewage Daily Flow * l7 gPd Residential .
Restaurant
*GP or WP areas restrict wastevwater discharge to 330 gallons per Retail 9/
acre per day into on-site syste . X
m 2�
Office
PARKING SPACES CURB CUTS Medical Office
Required Existing Commercial(specify)
Provided Proposed Wholesale(specify)
On-Site— To Close Institutional(specify)
Off Site Totals Industrial(specify)
Handicapped__ All Other Uses On Site
Estimated Project Cost: Fee: Gross Floor Area
$
SP-FORM P LDOC—06/18/2004
Old King's Highway Regional Historic District Pile# Approved? ❑Yes ❑No
.Hyannis Main Street Waterfront Historic District File#_ Approved? ❑Yes ❑No
Listed in National and/or State Register of Historic Places? ❑Yes []No
Previous Site Plan Review File# __ Approved? . -❑Yes ❑No
Previous Zoning Board of Appeals File# Approved? ❑Yes ❑No
Is the site located in a Flood Area(Section'3-5.1) ❑Yes ❑No
In Area of Critical Environmental Concern? ❑Yes ❑No
Is the Project within 100'of Wetland Resource Area? ❑Yes ❑No
Site sketch—informal presentation ❑Yes ❑No
.Site Plan prepared,wet stamped and signed by a Registered PE-and/or-PLS. ❑Yes ❑No
Parking and Traffic Circulation Plan ❑Yes ❑No
.Landscape Plan and Lighting Plan ❑Yes ❑No
Drainage Plan with calculations and Utility Plan ❑Yes ❑No
Building Plans,(all floor plans,elevations.and cross sections) ❑Yes ❑No
Note that all siEnaF_e must be approved by Code Enforcement Officer at the Building Department
Lot area in sq.ft. sq.ft
Total Buildings)footprint , sq.ft.
Maximum Lot Coverage as%of Lot %
\ GROUND WATER PROTECTION OVERLAY DISTRICT REOUIl2E ENTS: OVERLAY DISnUCf(S):
Lot Coverage (%) Required Proposed
Site Clearing (%) Required Proposed
PRINCIPAL BUILDING ACCESSORY BUILDING(S) ❑Yes. ❑No
Number of floors Height: fL Number of floors Height: ft.
FLOOR AREA: FAR: FLOOR AREA: PAR:
Basement sq.ft. Basement sq.ft.
First sq.ft. Fast sq.ft.
Second sq.ft. Second _ sq.ft.
Attic sq.ft. Attic sq.ft
Other(Specify) sq.ft. Other(Specify) sq.ft.
Please.provide a brief narrative.description of your proposed project:
� Z-"o �
I assert that I have completed(or caused to be completed)this page and the Site Plan Review Application and
that,to the best of my kno ledge,the information submitted here is true.
gels„ .t Date
Printed Name of Applicant
SP-FORM-PIDOC-06/18/2004
APPLICATION FOR SITE PLAN REVIEW SP# _
Date:
LOCATION
Business Name:_ � Subdivision Plan
Assessor's Map.# /-5 cel# 01 I_v` ANR Plan
Property Address: �1' " (,cl�, Site Plan
OWNER OF PROPERTY APPLICANT �^
Name: r/�L3 G`//i ��Li'-,ti r-�- Name:
Address: /_ T pG�-��/ Address:
Telephone: 5 /Z Y c S Telephone:Fax Fax: -S
ARCHITECT/DEVELOPER/CONTRACTOR/ENGINEER AGENT/ATTORNEY
Name: C{/fi CC.���z�.� � Name:
Address: _;2-11 6— Address:
Telephone: sm r Telephone:
Fax: Fax:
STORAGE TANKS(HAZ MAT/FUEL OR WASTE OIL) ZONING DISTRICT CLASSIFICATION
Existing Proposed District Jai l!� Overlays)
Number umber Lot Area Sq.Ft, Ac.
Size Size Fire District
Above Ground Above.Ground
Underground Underground Setbacks ft.
Contents Contents Front: Side: Rear.
Number of Buildings
Existing Proposed
UTILTDES Demolition
Sewer ❑ Public gr Private size led dal
Water ❑ Public ❑ Private " TOTAL FLOOR AREA BY USE
Electric ❑ Aerial ❑ Underground Existing Proposed
Gas Natural ❑ Propane (sq.fL) (sq.ft.
Grease Trap ❑Size gal Basement
Sewage Daily Flow *. V gpd Residential
Restaurant
*GP or WP areas restrict wastewater discharge to 330 gallons per Retail
acre per day into on-site system �� ��
Office
PARKING SPACES CURB CUTS Medical Office -
Required Existing Commercial ec'
Provided Proposed Wholesale(specify)
On-Site �— To Close Institutional(specify)
Off-Site Totals Industrial(specify)
Handicapped_ Ail Other Uses On Site
Estimated Project Cost: Fee: Gross Floor Area
$3
SP-FORM P LDOC—06/18/2004
rS,
Old King's Highway Regional Historic District File# Approved? ❑Yes ❑No
Hyannis Main Street Waterfront Historic District File#. Approved? ❑Yes ❑No
Listed in National and/or State Register of Historic Places? ElYes ElNo
Previous Site Plan Review File# _ Approved? ❑Yes - ❑No
Previous Zoning Board of Appeals File# Approved? ❑Yes ❑No
Is the site located in a FIood Area(Section 3-5.1) ❑Yes ❑No
In Area of Critical Environmental Concern? ❑Yes ❑No
Is the Project within 100'of Wetland Resource Area? ❑Yes ❑No
Site sketch—informal presentation ❑Yes ❑No
.Site plan prepared,wet stamped and signed by a Registered PE-and/or-PLS. ❑Yes ❑No
Parking and Traffic Circulation Plan ❑Yes ❑No
Landscape Plan and Lighting Plan ❑Yes ❑No
Drainage Plan with calculations and Utility Plan ❑Yes ❑No
Building Plans,(all floor plans,elevations.and cross sections) ❑Yes ❑No
Note that all signa a must be approved by Code Enforcement Officer at the Building Department
Lot area in sq.ft. sq.ft
Total Building(s)footprint �_sq.ft.
Maximum Lot Coverage as%of Lot %
GROUND WAM PROTECTION OVERLAY DISTRICT REOUIREWNTS: OVERLAY DISTRICT(S):
Lot Coverage (%) Required Proposed
Site Clearing (%) Required Proposed
PRINCIPAL BUILDING ACCESSORY BUILDINGS) ❑Yes. ❑No
Number of floors Height: fL Number of floors Height: ft.
FLOOR AREA: FAR: FLOOR AREA: FAR:
Basement sq.ft. Basement_ sq.ft.
First sq.ft. First sq.ft
Second sq.fL Second sq.ft
Attic sq.ft. Attic sq.ft
Other(Specify) sq..ft. Other(Specify) sq.ft:
Please.provide a brief narrative.description of your proposed project:
I assert that I have completed(or caused to be completed)this page and the Site Plan Review Application and
that,to the best of my kno ledge,the information submitted here is true.
Date
Printed Name of Applicant
SP-FORM-PIDOC-0611812004
`,UMMONWEALTH OF MASSACHUSETTS
z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
N N
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
�K
Y
6�
!�'aM cJOy
350 MAIN STREET /Jr25—61r O
WEST YARMO(1TH,MA
508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ✓?✓���
MAP 155—PARC 18
Property Address: 2415 MEETING HOUSE ROAD � �
ROUTE 149
WEST BARNSTABLE,MA 02668
Owner's Name: TOWN OF B__^RNSTABLE t rya
Owner's Address: 230 SOUTH STREET (jn "��
HYANNIS,MA 02601
Date of Inspection NOVEMBER 21,2005 !y
Name of Inspector:(please print) JAMES D. SEARS W '
Company Name: A&B Canco tv �-
Mailing Address: 350 Main Street t.J
West Yarmouth,MA 02673
Telephone Number: 508.775-2800
CERTIFICATION STA IEMENT
I certify that I have personally it spected 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 d).sposal systems. I am a DEP
approved system inspector puisuant to Section 15.340 of Title 5(310 CMR 15.100). The system:
•� Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local,approving Authority
Fails
Inspector's Signature: Date: 11-28-05
The system inspector shall st knit a col;; ui[his inspection report to the Approvire. /authority(Board of Health or
DEP)within 30 days of completing iius inspection. If the system is a shared systr:: or has a design flow of 10,000 gpd
or greater,the inspector and the >ystem owner shall submit the report to the apprel-:iate regional office of the DEP.
The original should be sent to the system owner and copies sent tot he buyer,if appl, able,and the approving authority.
Notes and Comments
****This report only describe;conditions at the time of inspection and under :ie conditions of use at that time.
This inspection does not addr+ how the system will,perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/1 ri 2000 1
� S
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
WEST BARNSTABLE.MA 02668
Owner: TOWN OF BARNSTABLE
Date of Inspection: NOVEMBER 21,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. -System Passes:if
I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
_ 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.
Answer yes;no or not determined(Y,N.ND)in the 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 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approvai of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15 2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
Owner: WEST BARNSTABLE,MA 02668
Date of Inspection: TOWN OF BARNSTABLE _
NOVEMBER 21, 2005
C. Further Evaluation is Required by the Board of Health:N/A
_ 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 salt marsh
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 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 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 N 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:
Title 5 Inspection Form 6/15/1000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
Owner: WEST BARNSTABLE,MA 02668
Date of Inspection: TOWN OF BARNSTABLE
NOVEMBER 21, 2005
D. System Failure Criteria applicable to all systems: N/A
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 pit is less than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion�of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)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: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 a 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 is 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.
„e.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST `
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
Owner: WEST BARNSTABLE,MA 02668
Date of Inspection: TOWN OF BARNSTABLE
NOVEMBER 21, 2005
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
if Were any of the system components pumped out in the previous two weeks?
if Has the system received normal flows in the previous two week period? .
✓ Have large volumes of water been introduced to the system recertly 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,including 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)has been determined based on:
Yes No
✓ 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 CNM 15.302(3)(b)]
Title 5 Inspection Forni 6/15/2-000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2415 MEETING HOUSE ROAD _
ROUTE 149
Owner: WEST BARNSTABLE,MA 02668
Date of Inspection: TOWN OF BARNSTABLE
NOVEMBER 21, 2005
FLOW CONDITIONS
RESIDENTIAL✓
Number of Bedrooms(design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 550
Number of current residents: 0
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): WELL
Sump pump(yes or no) NO
Last date of occupancy: UNKNOWN
CO MMERCIALANDUS TRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
N/A
Were sewage odors detected when arriving at the-site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2415 MEETING HOUSE ROAD
_ ROUTE 149
Owner: WEST BARNSTABLE,MA 02668
Date of Inspection: TOWN OF BARNSTABLE _
NOVEMBER 21, 2005
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Conunents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 4"
Material of construction: concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000-GALLON PRE CAST
Sludge depth: F,
Distance from top of sludge to the bottom of outlet tee or baffle: 29"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: ASBUILT&TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK AT WORKING LEVEL,INLET TEE—OUTLET BAFFLE.
NO SIGN OF LEAKAGE OR OVERLOADING.
GREASE TRAP(located on:site plan) N/A
Depth below grade:
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:
Comments(on pumping recommiendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence-of leakage,etc.):
Tide 5 Inspection Form 6/1512000 7 f
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
Owner: WEST BARNSTABLE,MA 02668
Date of Inspection: TOWN OF BARNSTABLE
NOVEMBER 21, 2005
TIGHT or HOLDING TANK: N/A (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 Floe: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Continents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.,):
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
Owner: WEST BARNSTABLE,MA 02668
Date of Inspection: TOWN OF BARNSTABLE
NOVEMBER 21, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
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.)
LEACHING IS ONE 1000-GALLON PRE CAST PIT.
PIT AT 39"WITH COVER AT 16".
PIT IS DRY WITH STAIN LINE AT 30".
NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
CESSPOOLS: N/A , (cesspool must be pumped as part of inspectionklocate 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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate„r-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.)
Title 5 Inspection Form 6/15i2000 9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
Owner: WEST BARNSTABLE. MA 02668
Date of Inspection: TOWN OF BARNSTABLE
NOVEMBER 21, 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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Title 5 Inspection Form 6/I5/2000 10
Page I I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2415 MEETING HOUSE ROAD
ROUTE 149
Owner: WEST BARNSTABLE, MA 02669
Date of Inspection: TOWN OF BARNSTABLE
NOVEMBER 2 L 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
OBSERVATION AT ff NO WATER.
TEST HOLE 3' BELOW BOTTOM OF PIT.
BOTTOM OF PIT AT 9'BELOW GRADE.
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Title 5 Inspection Form 6/15/2000 I 1
Page:
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 08/05/2002
REC.FV
Order Number: G0216388
John Caiaze AUG 15 2002
P.O.Box 699
` Sagantore, MA 02561 TOWN 0
HEALTH
DEPT. SLE
Laboratory ID#: 0216388-01 Description: Water-Drinking Water
Sample#• 16388 Sampling Location: 2415 Meeting House Way,W.Barnstable Collected: 07/31/2002
ollected by: J.Caiaze j Sb I ¢ �d Received: 07/31/2002
Routine
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:IC Lab
Nitrates <0.1 mg/L 0.1 10 EPA 300.0 08/01/2002
LAB: Metals
Copper <0.1 mg/L 0.1 -1.3 SM 311113 08/02/2002
`Iron 2.4 mg/L 0.1 0.3 SM 3111B 08/02/2002
Sodium '10 mg/L 1.0 20 SM 311113 08/02/2002
LAB:Microbiology
Total Coliform Absent P/A 0 Absent P/A 07/31/2002
LAB: Physical Chemistry
Conductance 111 umohs/cm 1 EPA 120.1 08/01/2002
pH 6.7 pH-units 0 EPA 150.1 08/01/2002
Note: Based on the results of the parameters tested,the water is suitable for drinking but may present aesthetic problems(taste,
odor,staining)due to Iron..
Approved By:
(Lab Director)
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Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
(/ TOWN OF BARNSTABLE
LOCATION r t`s �Lj y SEWAGE#
-VILLAGE Iit/ — /,1/f'N ASSESSOR'S MAP&LOTAr
INS LA£CT S NAME&PHONE NO. 19
SEPTIC TANK CAPACITY .S Ter ti, C 71 G A l
LEACHING FACILITY.(type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER o
PERMIT DATE: CGAV14ANCE DATE: iZ S -o f
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
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AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
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LOCATION 2�f1 me¢��n� {{� �JZd , SEWAGE #_
VILLAGE_S.,tr7, r5 0 A 3 . ASSESSOR'S MAP & LOT—)
INSTALLER'S NAME & PHONE NO.
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SEPTIC TANK CAPACITY ,LL__j '3-74
LEACHING FACILITY:(type) Pi j (size)/0£7Z:� Glq I
NO. OF BEDROOMS ,,mot! PRIVATE WELL OR PUBLIC WATER C+.r 14 I
BUILDER OR OWNER'C7/-i rt l D,
DATE PERMIT ISSUED: (V f
DATE COMPLIANCE ISSUED: — - Yy- 7
VARIANCE GRANTED: Yes No Lam.
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UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS fRAt(., I M,vri
ASSESSORS MAP NO. PARCEL N0.
ADDRESS: et y/y /J�CFT/A/G Alp ose U)A v VILLAGE: Z24 A".SrA kq<„k'r" of
14AME; 4�'uA 4 D 7- �,�2Q�c Tt/�I- ,�t//�s 5d•✓-- _
CONTACT PERSON E, Na S$oal PHONE NUMBER 3
LOCATION OF TANKS CAPACITY: TYPE OF* FUEL. AGE: TYPE: LEAK
OR CHEMICAL: DETECTION
y/y ,�f��Tiv6,clov -& ��_T i6o C44- ,fv,�c O�c ZT�Q, ST��� SYSTEM,
04 kk 4v-45 /7FPZ459 *--' /9R
DATE OF PURCHASE OF EACH: 1. /g8 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT: ?
TESTING CERTIFICATION SUBMITTED: PASSED ' DID NOT PASS
.PLEASE PROVIDE .A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. f
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LOCATION 2�1 '� /Yle��,n� 4-6 J2u . SEWAGE #
VILLAGE?a (�, 1: n ASSESSOR'S MAP & LOT ^ l�
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /L)Z
LEACHING FACILITY:(type) ` # (size) 0 -7--) 6-1
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NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER&tern
BUILDER OR OWNER-p f) f @✓
DATE PERMIT ISSUED: �Y/ `�� /
DATE COMPLIANCE ISSUED: 7
VARIANCE GRANTED: Yes No l_�
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Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.
APPLICATION and PERMIT
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
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Tank Owner Name(please print) �'��U � 1
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ature � nm vp/yang or pe !
Address 6� / E? !lt.1S� L K) f?S/ �gn t ' `
Stre t City State Zip
• • " • • • '
Company Name �" �1"041l>e� -fir_ Co.or Individual
Print
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Address --f_�. v � // Address
"print [�J sG3 not
Signature(if a g f ermit Signature(if applying for permit)
O IFCI Certified Other O IFCI Certified O LSP# Other
"Tanktion
Tank Capacity(gallons) Substance Last Stored %
Tank Dimensions(diameter x length) "'k-- ��e
Remarks:
Firm transporting waste
Alan(? �4 . State Lic.# ';j ��� '�
Hazardous waste manifest# /_� —E.P.A.#
Approved tank disposal yardAm `� �`" `"`'" `e_Tank yard
� �' # 1
Type of inert gas Tank yard address �( t
CityorTown l�t.-S` 'E/AZ&5`_AJ3LX- -t � f-'`,2tt.� FDID# _—_Permit# 38-17 _
Date of issue r! 1 el _ Date of expiration o 3 A fr, 9 s
t Dig safe approval number: } ig Safe Toll Free Tel, Number-800-322-4844
Signature/Title of Officer granting permit --
-After removal(s)send Form FP-290R signed by Local Fire Dept, to UST Regulatory Compliance Unit, One Ashburton Place,
Room 1310, Boston, MA 02108-1618.
FP-292(revised 9196)
SSESSORS MAP NO: _a"167�r
'ARGEL NO.: 7q6
No.. Fims...-�i.Jw
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Aliptiration for Bhip a al Workii Tnnitrnrtiun Vantit
Application is hereby made for a Permit to Construct ( ) or Repair (4-ran Individual Sewage Disposal
System at:
................`�.............. ............. .:. � --------------------------------------
-Add ess o Lot No.
.: _ � `''
.............
Owner Address
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�:r31 �1! 1. 'ice`l J fK_.. - f'!_...................... :._ A:_..�"!__&.---•------------------•-•---...._..--------
Instzller Address
QType of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms._._____________________ __ _Expansion Attic ( ) Garbage Grinder ( }
-----------
aOther—Type of Building ____________________________ No. of persons---------- )'_............. Showers (P--) — Cafeteria ( )
dOther fixtures ------------------------------------------------- ------------------------------------------------�- -----------------------------------------
W Design Flow....... ..........................gallons per perso Der day. Total dam flow......:3..a_.0....__....___.._...._._gallons.
1:4 Septic Tank—Liquid capacity/dA gallons Length 4l!___._._.._._ Width.... ......... Diameter---------------- Depth................
Disposal Trench—\To_ ____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft.
..
Seepage Pit No-------/----------- Diameter....... ......... Depth below inlet_-��---_C_.�_...______ Total leaching area..................sq. ft.
Z Other Distribution box ( Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------..................
--------•-------------------------------••----•----------- ........................................ ..........................................
Description of Soil -- ........... .... •-•--•--•-•-----
U
W -------•-----------------------------•••------•----------------••-•-•-•----••-•••-•--------•-----------•----------.._....-•---------------------------------------------•-------•------ •-_...•-
Nature of Repairs or Alterations—Answer when a licable.__ ' z�! _--__ 6f _.._
U P PP y - r.-•-...--•- -----v -----
- '✓ = ��: - �L'��' ✓+ ...�. _.h>>'< t f .......................•--.........._..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of is"L L ;of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed9fU' ._:-�- ljr.- '
s' D r .. ...............................
Date
Application Approved By..-- --------- ................................
Date
Application Disapproved for the f ollo •n reasons-----------------------------•--•----------------------------------------------------------------.............._
--------------------------------------------•-------•--------...-•------•---------------•-•---.....--------------------•-------------- --••-•------------------•---------------•-•----•--•--...._....
Date
Permit No..- .... Issued................
Date
No.-_ _-_- ._.... FE$............._....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.......................................-...............................................
Appliration for Dispoiial Works Tonstrtirtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.... - •--•............. ......... .... ..._.._.._....
.....-•-
Location-Address or Lot No.
......................—.......................................................................... --..._..._....--------------...
Owner Address
w
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa-1 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p" Other fixtures .....................
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid'capacity_-_____-----gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—\?o..................... Width......_............. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-•••••••-•--------------------•-•••••-•-•-....•-••--••--•-•••........_.__-•-•-•-•--•--•-•-----•••••.........................................................
ODescription of Soil.......................................................................................................................................................................
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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 i-Tt.- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed ----------
Application Approved BY __.........L � -----------•-----•--•---
Date
Date
Application Disapproved for the f ollo i reasons---------------------------------•-•---------•---•---•--•-----------------------•-•----••--••••••-•••-----•--•-
i
1 Date
Permit No..ID
Date
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..............................................................I.................
(Irrtif iratr of iff-otnplittnrr
THIS IS TO CERTIF�,-) hat tqe Individual ge Disposal. System constructed ( ) or Repaired ( }
by............................................... `y................� --_--___-_--------•--_-_--•--•-•------------_.____--------•----_-_-_
`--
has been installed in accordance with the provisions of T i T i 5 f._The�State Sanitary de as des q d in the
application for Disposal Works Construction Permit No.._.L)._�"._.._D. L r ..._... dated_... : _`___-
PP P �•s Pam• --;:.>--;,�-- �-�--=-� ------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........._•..............1�... . _.-- ---------•--------- Inspector.................. ............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NO. ...........•.......... FEE........................
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Permission is hereby granted......... 1 _ / ............ .,._..�Jt
to Cons!52g (cam,) or Rj�epai ( ) ant Individual
}S .wage Disposall /S stem
at No..•--._._.._.,_.�1.........L�_,_T-�`-1_"`7�_�-1-�/��.5. 4'�!!c..�.. ... .A/.�1..._....... ..�...............................
t. { -----.....
� �'� Street ,� Z�� / —7
as shown on the application for Disposal Works Construction Per t Nol =.5_).._. Dated.__.__ __'.l_.__.1...-.
--_._•••-•......--• -•-• ••-••-•-•-- -------------------------Boar Health
DATE.......... -----•-•----f----�---1-/•--1-----•--------------•----•--•------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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SEPTIC: EXISTING DWELLING• (3 BEDROOMS) = 330 GPI
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CAPACITY REQUIRED: 450 GI:,,
CAPACITY PROVIDED: 550 GPDDz
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/ MINIMUM LOT SIZE .43560 S.F.
MINIMUM FRONTAGE: 1 60,
�� /44 MINIMUM FRONT,YARD: 40'
-MINIMlJM 51DE * REAKvYAKD: 30'
- /.
- MAXIMUM 'BUILDING H'fIGFiT: 3.0' i.
\ - / / =f. MAXIMUM LOT COVERAGE: 10%
-{- ORD OWNER:: TOWN . F BARNSTABLE '
- / / 43.5 — -'�46 L 55EE4 APPLICANT: ED CC UTURE '
- 24j.1 5 MEETINGHOU'5El WAY
WEST BARN5TABLE, M�
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/ EXISTING .G'.x G' /
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' CAPACITY = 550 GPD
48.2 -
E:.ISTING 10�?0
GALLON SEPTIC \ 1
TANK
�v! j` EXISTING DV/>rLLINt�
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RE-MI�DEL.I-EO c)FAV
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CONCRETE
RETAINING. 50. 1 -
/ WALL / 50.2
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CONSTRUCT SWAL� S
TO DIRECT RUN 01=� `�. `FA�R1Ctticx
(SEE DETAIL) 51 .5. . --`----_. `. • `\\ �' ''
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/ / 53-2 CUR4.CUT
50 +53.7 }- \ `TO...BE W1DENCI)�i
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EVERGREEN i!' 3f _ K7 :•
-- / SCREENING !! ,�r
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54 LAN F LAN
5 .4 s D.
5 .G . `c FOR
E O U AY 5T S B ,
24 15 M ETINGh SEW UVE BARN TA LE MA..
PREPARED FOR
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DATE:
q_ ESS f! SCALE: n — '
F I — 2 O ' DRAWN BY:
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JOB'NUMBER:. REVISION: SHEET NUMBER
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W LLFR A55O.0 I ATES
1 G45 FALMOUTH Pl). 5UITE 4C --- P.O. 'BOX 417 CENTERVILLE, MA 02.G 2
2 WINDY WAY, #232 NANTUCKET; MA 02554
TELEPHONE FAX: (508) 775-0735
? EMAIL': trl5weller@comcast.net
- iY11NTA LTAfTS
' REGISTERED LAND 'SURVEYORS �. ENVIR.O h CON�LJ
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