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Home My WebLink About0255 PERCIVAL DRIVE - Health 255 Percival Drive West Barnstable A= 111 —065 s� �I i I i 'I �j I i I i I I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 255 Percival0jr/" -g.w-E.) Property Address George Bowman Owner Owner's Name information is required for t/ W.Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of_lnspecti6h /// --06 S Inspection results must be submitted on this form. Inspection f o e a ere in any way. Important: A. General Information When filling out forms on the 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 rQ P.O.Box 763. Company Address Centerville Ma. 02632 City/Town State Zip Code (508(428-4028 Telephone Number License Number B. Certification _ J I certify that I have personally inspected the sewage disposal system at this ad6ess 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 t6jSection'15.340;of Title 5(310 CMR 15.000).The system: 9 .® Passes ❑ Conditionally Passes ❑ Fail 0-) ❑ Needs Further Evaluation by the Local Approving Authority 3/15/2007 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future nder the same or different conditions of use. 255 percival way-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 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. 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 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. 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 255 percival way•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 31.0 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 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. 255 percival way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 255 Percival way M Property.Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection B. Certification cont. C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 255 percival way-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 255 Percival way Property Address George Bowman Owner Owner's Nane information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems.(cont.): Yes No [i ® Any portion of a cesspool or privy is within a Zone 1 of a public well. EI ® 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. 255 percival way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 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: ❑ Z 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)] 255 percival way-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. . 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2005:60,000 g ( y g (gpd)): 2006:38'000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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: Last date of occupancy/use: Date Other(describe): I 255 percival way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: unknown 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 255 percival way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet 0'+ 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 orr site plan): 2'8" Depth below grade: 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: 8'6"x4'10"x57' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 30" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? measured 255 percival way-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 255 Percival way Property Address George Bowman Owner Owner's Name information is W Barnstable Ma. required for 02668 3/15/2007 every page. City/Town 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.): Pump septic tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No evidence of leakage. Grease Traplocate on site plan): ( p ) 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 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): 255 percival way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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 level and has one 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 255 percival way•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnsta'ble Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: 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.Leaching pit was dry at time of inspection. i 255 percival way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 255 Percival way Property Address , George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 255 percival way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. N \ � 1 O \ 255 percival way-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 255 Percival way Property Address George Bowman Owner Owner's Name information is required for W Barnstable Ma. 02668 3/15/2007 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 ground water: 90 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:Gaherty& Miller Model 12/16/94 ground water elevations.Used:USGS observation well data June 1992.Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations t 255 percival way•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 i oo, IJ� 4.- t LK �--��--- r y O/� SJT I-W6 cS•� �r��6 i TOWN OF BARNSTABLE i LOCATION .La/ /9 A5_4(!/-/l-,tq 4--2r_§EWAGE # U---2_VD VILLAGE t_3 ASSESSOR'S MAP & LOT _ INSTALLER'S NAME & PHONE NO. h$IQ (b jJS'a 711-Ul Lg SEPTIC TANK CAPACITY 0Q Q LEACHING FACILITY:(tVpe) (size) Ta6 NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER UILDER OR OWNER 'V-142-j DATE PERMIT ISSUED: Z3 DATE COMPLIANCE ISSUED: I?3 VARIANCE GRANTED: Yes No 1 _ t r 6 � lhl� THE COMMONWEALTH OF MASSACHUSETTS 12�r BOARD OF HEALTH ...old-n ...............OF........bxn5bLble-------•---..--..--••---------•------•---- Allp iratiun for Uiipuiial Workri Tomlrur ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System-at � c .�J L.....Id.a........_....La.b.:... .................................................. . L t n ess or Lot No. -----------------------------•--•-----.... - Owner Address ---------------!A... ------------........................................................ ....--•••----•------------.....................---.........._......_..._..__.._....------......._. Installer Address � III Type of Building Size Lot_3.�.�__'71-5.....Sq. feet U Dwelling—No. of Bedrooms............ ___________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixture ..._ d Design Flow________________, _ _..____________._gallons per, person per day. Total daily flow......................at3Q.........gallons. 9 Septic Tank—Liquid capacityilM__gallons Length................ Width._._-........... Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length...........w....... Total leaching area....................sq. ft. Seepage Pit No..........i.......... Diameter.....1_f0-------- Depth below inlet....... _........ Total leaching area__,ZG(0...sq. ft. z Other Distribution box (V� Dosing tank ( ) '-' Percolation Test Results Performed by..___._So-qLe.... cn__1.n.e_U�Y��___ Date........................................( aTest Pit No. 1................minutes per inch Dept7i of Test Pit--__-_-_-__--._-___ Depth to ground water........................ � Test Pit No. 2_...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil.................Q-- 1}-5-......... q?--.:i-....5_0_1aj-••---------•-------- ------------•---------------•---•-----------....--------- U =--••------------•-••-•-------------------•----•-1.- .__-_! r ....--- U 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 Complia s been issue d-b} oard pfhealth. Signed ..... .. ..... f - G . ------------------------- --------- -.. ......... ... Application Approved By ... .. - == .. te Application Disapproved for the following reasons: ........................................................................................ . ------------------------------------- --- -------------- - Dace Permit No. .. .................................. Issued .. ---- -��----�/,/-- V �p e - ' -----------........... No................_....... - I ( . ' Fps............................_ THE COMMONWEALTH OF MASSACHUSETTS ' `'�' BOARD OF HEALTH E-D W n.................OF.........r(Da(.(lam, `t t-e..--------- ApplirFation for Disposal Works Tonstrurtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: r n I ..... ..1. ��.' E.�l �.i�...... ' :9��.............�.��:.�5:... _....-•---......----•-•...........••---.. -----j-� ......... Location;A'dd'ress or Lot No. / r/ 0,/ caner .Address n W •-•-•----•- =v� ........ ---• --- --------------•--- ••--•-•---- ---•••.---...............---•-----•--.... Ins ller Address L � Type of Building Size Lot.. �..t......�_:?.._..Sq. feet Dwelling—No. of Bedrooms............j...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aI Other fixtures.-- ---------------------------- W Design Flow................:S ...................gallons per person per day. Total daily flow......................a.34 n.........gallons. WSeptic Tank—Liquid capacity$.ffly-gallons Length................ Width....`.......... Diameter................ Depth............. x Disposal Trench—No. .................... Width.................... Total Length..........!>-_f.... Total leaching area....................sq. ft. Seepage Pit No----------�.---_--_-. Diameter.__.. _�......_. Depth below inlet.......&........ Total leaching area..�:.o�__:._.sq. ft. Z Other Distribution box ( Vf Dosing tank ( ) aPercolation Test Results Performed by.......�33C?� .... ! < `.0► E r'�-J.� ... Date.......-. . .�.�`:.�... .... 1.4 Test Pit No. I................minutes per inch Deptli of Test Pit ............... Depth to ground water........................ G%I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W •-•••-•-• ---•-------------•---•-•-••-•--•••-•--••----•......•----•..............-----------•........-•---•----•-••--•-•----•...............----......... O Description of Soil-----------------(� - ?......:.. ::' � 2-Liz------------- v .---------------•••.... ..••-----•---••---...• ....1._,5---•'.- 1-'-5........-'n�J> �L9. W.1_4b---•-.C'�CJ.zai e. .,..t.L.ob te{ 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 CompliAcce-has been issued-lam oardt,heeaalth. Signed ....... .... .<�•�-. -c -. Application Approved BY / - / Date ' / - Applicatio6 Disapproved for the following reasons: .......................................................... ....'-... -...-- -- ....-................................. Permit No. --------.--, .�'..��.....�....---... / .'�.�_�-- ---................................Date Issued .--------- -- - -- - ✓ 'Dale THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ _�..t --------------- OF .......... -----------...............:..----...----------------------------------- C�er#t�tctt#e of C�om�ltttz�.cP THI J& TO CF TI That the Individual Sewage Disposal System constructed ( t'' ) or Repaired ( ) y^ tom? Installer L at - � - - ... .. ..1.� ¢:� Z . _..................................t).,.....�.'.---......................................................... 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. ..0 *-J, of7 0'0 dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT.THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........7-`----- ------------------------------- -- --------- Inspector ...... s THE COMMONWEALTH OF MASSACHUSETTS BOARD : F HEALTH / �1 I ,.......... .�1........... OF......... � [ fi� a . 1 ' < No.....:...... ......:.... FEE....................... Disposal Yor�'� no#r tialn rrmit Permission is ereby granted 1 . ...----- � to Construct ( f or R pairs( ) � Individual Se�ragS psposal System . at No.......................�:4•�••-.L�.....-- " C�,.C.!�� .c lCc.. ------- j�C�:. Street t' � •��f�,,.�f � as shown on the application for Disposal Works Construction ��-,Dated..._., ......... 2(,, Board of Health DATE. / -----------------•-••----------------.... FORM 1255 HOBBBS & WARREN, INC.. PUBLISHERS ,. � i -ter No. �ilJ --- ''�J' Feed-- �'-- ----- - --- BOARD OF HEALTH TOWN OF BARNSTABLE ZIpplicationforVerr Congtructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( an individual Well at: -----—------------ -- ------------------------- ----- -___-- -- — - Location — Address Assessors Map and Parcel Address _ f � ,t d"_c --- --------------- _,� l't, f� -------- ---------- Installer — Driller Address Type of Building Dwelling---------- ---- - ----------------------- Other - Type of Building----------------------------- No. of Persons-_-___-_____________�________—_ Type of Well- -- -- - ----- --- Capacity---------------------------_ Purposeof Well------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The.undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed I--- L %l r f date Application Approved By- date--�� Application Disapproved for the following reasons: ------------------ — �r date Permit No. ---- ----- --�-- - Issued— date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by-_ —�- �_� -N ------------------------ - ---- ---- __ _--- --- GG O Installer n 1---�-�-1�----�- L�q-r----------- ' has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ted127 —' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- --- ----- - - ------ — - Inspector---------� — -- ---_ — t i No.-� - ''� `' Fee- -- BOARD OF HEALTH TOWN OF BARNSTABLE Appritation-*rVell Cootructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (,,+)'a individual Well at: P,`_ �'Ls 1► ------------------------------------------------------------- ----------------------- - Location — Address Assessors (Map and Parcel ry�� Ownei Address / ^%----------------- Installer — Driller Address Type of Building Dwelling-------------------------------— -- - -- Other - Type of Building -- No. of Persons------------------------------------------------___ Type of Well- -�✓- - f_1 ='- Capacity------------------------------- Purpose of Well-----------— - -- ---- ------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed r date '''' Application Approved By- ------ Application -- 'L=--"-� PP PP Y- -=- ---- -- — —— -----date _---- Application Disapproved for the following reasons:----------?--------------------- - - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- date Permit No.------- =� ' `� / -------- Issued- —=' - --------- ---------------------- date 9 BOARD OF HEALTH TOWN OF BARNSTABLE Certificate (Of Compliance THIS IS.TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by-----44--- ---------------------------- ------------ - ------------------------------------------------ — - Installer ------------------------ I at------- _ - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. T,,'-q---1 ated---4`a�---� -") THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------------------------------------------------- Inspector----------------------------------------------------------------------------- ---, BOARD OF HEALTH TOWN OF BARNSTABLE Yell Congtruct ion Vermit fj No. —�'��-- Fee��___'��"__ Permission is hereby granted-- � � -- r---- !�� - ------------------------------------------------------------ / - P/j�`v to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at: No. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Street as shown on the application for a Well Construction Permit q No. Dated ------` v: d -- — ----_- -- - y Board of Health DATE--------------------- --------------------------- 10 - _ �� • . : . : PET- ;TRrAa , I►� O�tld i �jPAt� ��`Qd q ,2CD,93 ILsoo �ttd- f: ` ----'-/ic .04 Imo, . w� .�c:�t►o�I Lo��'a¢ats � 'r• . I��'os�.� '.�..- -.--�vZ. `O. AAA5TEL FL,4.,Q ao `Pw EL l uC, , `. to r. OF 4j ti s. PETER SULLIVAN No. 29733 ti \Q IONAL • o o ray ._; .. :.,.. . Yslti•1 _ .. .. .. __ dog Number: Bottle # 01510 Date: May 14, 1993 BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT tl, l� d SUPERIOR COURT HOUSE v BARNSTABLE,,MASSACHUSETTS 02630 0 0 1yA56 DRINKING WATER LABORATORY ANALYSIS PHONE:362-2511 _Ext..337 Client: Tartan Inc Collector: -C Stiefel Mailing Address: P 0 Box 1198 Affiliation: BCHD West Chatham MA 02669 Time & Date of Collection: 5 12 93 2:05 .m. Telephone: . Type of Supply: well Sample Location: Lot 19 Percival Lane Well Depth: 71' W Barnstable. MA Date of Analysis: 5/12/93 4.30 p.m. PARAMETER SAMPLE RESULT RECOMMENDED LIMITS j Total Coliform Bacteria/100 ml 0 0 { H. 6.0 Conductivity (micromhos/cm) 95 500.0 Iron ( m) 0.1 0.3 Nitrate-Nitro en ( m) 0.4 10.0 Sodium m) 19 20.0 Copper (ppm) 0.1 1.3 I. XXXX Water, sample meets the recommended limits for drinking of all above .tested parameters. II . Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends. B, The low ,pH of the water may shorten the useful life of the house's plumbing. C. Water may present aesthetic problems (taste, odor, staining) due to Water sample has high levels of sodium: Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below; this water sample exceeds the recommended maximum contamination level for drinking water: A. High Bacteria B. High Nitrates REMARKS: CC: BOH C C: 117/85 Laboratory Director 1 xpla a,'on of+cst Results Total Coliform Bacteria Coliform bacteria are an indicator of t`:e sanitary gt:aliry of a ,yater supply. Water supplies may s rcr• contaminated from malfunctioning septic systems, cesspoolz and surface runoff. A total coliform cnun :-,f 7^ indicates that your water supple is safe and approved for human consumption. A total coliform count of grontm- t zero is most often the result of accidental ^tar.. narinr n1 tc, :ample bottle thrntteh immmper -,ami olive mr ~, ';. For this reason, it would be advisable :hat `,., ,;;�; approvec . pH pH is the measure of acidity oralkalinitcof the l•atcr. On tl,t: pH scale, the number i is neutral. less than " is acir'ic and more than ' is alkaline. The pH of .atcr on Cape <,,1 -ends to be acidic in the range of 5.0 To 6.5. Conductivity Conductivity is a measure of the dissnlved salts ir, s:;lutinn. Amounts in excess of 500 micromhos/cm are genera;ly considered unacceptable and may have a laxative c-F-Fect upon users. Iron The presence of iron in water in concentration of .3 pp7y, or greater may: give the water a bittersweet astrine?'t taste, cause an, unpleasant odor. often gives the warcr a >h color and cause staining of laundry and pnrce;a::,, The average concentration of iron in Cape Cod's. `rater is .i - .it ppm. Although the presence of iron in water may cause the problems listed above. it is not considere;; del ete rim is to health. Iron may be removed by use of an iron removal system. Nitrate-nitrogen The Massachusetts Drinking Water Regulations lhr.yc s-1, a s,aximum contaminant level for nitrates at 10 ppm. Excessive concentrations may cause methemoolobinemia (an infant disease) and have been suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Copper Due to the acidic nature of the water on Cape Cod. copper tends to leach from pipes. This normally does not present a health hazard: however, concentrations in czc:ess of 1.0 ppm may cause a metallic taste and/or a bluish-green stain on porcelain fixtures. Sodium A concentration of sodium over 20 ppm is only ,:,f :,:ncerr- -r• people who are on a Irnv sodium diet. If the water supply has more than 20 ppm sodium, it is up to the ne:,nlr Nv,ho are m such a diet to find another source of drinking water or contact their doctor to determine if consu=t,ing the �� iter is advisable. Concentrations exceeding SO ppm inci`,:ate that there may be ocean water or road sale rt;:•wff ware; getting into the well. w �f BARNSTABLE COUNTY ,HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS Client: TARTAN INC Collection Date : 05/12/93 Mailing Address :P 0 BOX 1198 Date of Analysis :05/13/93 WEST CHATHAM MA 02669 Type of Supply: WELL Well Depth (FT) : 71 Telephone: Sample Location: 19 PERCIVAL LANE LAT. (DDMMSS) : Not Given BARNSTABLE LONG. (DDMMSS) : Not Given Collector: C STIEFEL Map/Parcel : Affiliation: BCHD Analytical Method: 502;1=1 , 502 . 2=2 , 503 . 1=3 , 504=4 , 524 .1=5 , 524 .2=6 , 502 .1/503=7 Contaminants Anal . Result MCL Detection Detected Meth. ug/l ug/l Limits (ug/1) --------------------------------------------------------------------- Chloroform 2 2 .1 0 . 5 Only those compounds listed above were detected. Attached is a list of compounds for which this sample was analyzed. NOTE: Contaminant levels equal to or exceeding the Detection Limits are reported. MCL means Maximum Contaminant Level for EPA-regulated compounds . (ug/1 = micrograms per liter = Parts Per Billion) The Environmental Protection Agency has set Maximum Contaminant Levels (MCL) for the following compounds . This sample compares as follows : COMPOUND MCL (in PPB) Benzene 5 .0 * level not exceeded * Carbon Tetrachloride 5. 0 * level not exceeded * 1 , 2-Dichloroethane 5 . 0 * level not exceeded * 1 , 1-Dichloroethene 7 . 0 * level not exceeded * 1 , 4-Dichlorobenzene 75 * level not exceeded * 1 , 1 , 1-Trichloroethane 200 * level not exceeded * Trichloroethene 5 . 0 * level not exceeded * Vinyl Chloride 2 . 0 * level not exceeded * Comments or additional compounds. found: + Thomas F. Bourne , Laboratory Director Log-'Number: Bottle # 01510 Date: May 14, 1993 of s��pti a, sa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE v BARNSTABLE, MASSACHUSETTS 02630 a e �rg55 DRINKING WATER LABORATORY ANALYSIS PHO NE: 362-2511 !-Ext. 337 Client: Tartan Inc Collector: C Stiefel Mailing Address: P 0 Box 1198 Affiliation: BCHD West Chatham MA 02669 Time & Date of Collection: 5/12/93 2:05 p.m. Telephone: Type of Supply: well Sample Location: Lot 19 Percival Lane Well Depth: 71 ' W Barnstable. MA Date of Analysis: 5/12/93 4:30 p.m. PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml 0 0 H 6.0 Conductivity (micromhos/cm) 95 500.0 Iron ( m) 0.1 0.3 Nitrate-Nitro en ( m) 0.4 10.0 Sodium ( m) 19 -20.0 jt Copper (ppm) 0.1 1.3 I. XXXX Water sample meets the recommended limits for drinking of all above tested parameters. II . Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends. B. The low pH of the water may shorten the useful life of the house's plumbing. C. Water may present aesthetic. probiems (taste, odor, staining) due to D. Water sample has hig h levels o d'p f so ium: Persons on low sodium d', 9 u lets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample exceeds the recommended maximum contamination level for drinking water: A. High Bacteria B. High Nitrates REMARKS: CC: BOH CC: 1 /7/8! � Laboratory erector Explar:alinn of Test Results f Total Coliform Bacteria Coliform bacteria are an indicator of they sanitary quality of a water supply. Water supplies maY ber�,r contaminated from malfunctioning septic systems,, cesspools and surface runoff. A total Coliform count of 72r indicates that your water supply is safe ar.d,approved for human consumption. A total Coliform count bf greate-,hnn zero is most often the result of accidental cnntnr.�inntion of the sample bottle through imaro7_ er samolinQ mrl,nt':s. For this reason. it would be advisable rc eq ;ii;i: ev ll ;)rer that s ;got apprOVecl. .pH pH is the measure of acidity oralkalinit'vof the water. On thc, p.H scale, the number 7 is neutral. less than 7 is acidic and more than 7 is alkaline. The pH of:rater on Cape t od tends to be acidic in the range of 5.0 to 6.5. Conductivitv Conductivity is a measure of the dissolved salts in s;)ltitinn. Amounts in excess of 500'micromhot%cm are generaliv considered unacceptable and may have a laxai ive cf`ect upon users. Iron The presence of iron in water in concentration of .3 p ;rn or greater may: give the water a bittersweet astringent-4 " taste, cause an unpleasant odor, often gives the water a b.ro.vnish color and cause staining of laundry and porcelain.0 The average concentration of iron in Cape Cod's `eater is .2 - .6 ppm. Although the presence of iron:in water.mav cause the'problems listed above', it is not considers d le*.erioits to health. Iron may be removed by use of an iron removal system. Nitrate-nitrogen The Massachusetts Drinking Water Regulations hr,vc sct a n,ammum contaminant level for nitrates at 10 ppm. Excessive concentrations may cause methemoolobitiemia On infant disease) and have been suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers.'cesspools and-industrial wastes. Copper Due to the acidic nature of'the water on Cape Coda copper tends to,leach from pipes. This normally does not present a 'health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish-green stain on porcelain fixtures. ..t; Sodium A concentration of sodium over 20 pnm is onlY of .nncern n,, people who are on a low sodium diet.Af the water supply has more than 20 ppm sodium, it is up to the ne inic who arc on sitch a diet to findianother source ofidrinkine water or contact their doctor to determine if coi;sumint, the �vater.is advisable. Concentrations exceeding 50 ppm imil::ate that there may be ocean water or road salt'ronoft waxer getting into the well. Department of Environmental Management/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION Address es e? a 0A_L N S E W of (feet) (circle)' City/Tc- 4R Well owner �/�r 7 f %�t �� (road) Address N S- E W of t ry in tenths/ (circle) Board of Health.permit: yes 0/no ❑ intersect. w/ (road) WELL USE _ WELL DATA Domestic ❑Public❑ Industrial ❑ Total well depth r ft. Monitoring❑ Other Depth to bedrock ft. _ Water-bearing rock/unconsolidated material: Method drilled 4�, Description r. ,rilled -<� Water-_bearing zones`. G 1)'From To I/ 2) From' To �� ft. Dia(J.D.)�_In.. 3) From �1' To Length into bedrock ft. Gravel pack well: dia. Protective well seal: p d Screen: dia. Grout-❑. Other Sloto /e length 3 fromIS to�1_ WELLTEST _ Static water level below land surface r ft. Date Drawdown 42 ft. after pumping "61 hr.-min.at ./ef-2 gpm How measured n Recovery. ft. after-hr. min. O LOG of FORMATIONS COMMENTS. Materials From To Mass. Registration* Firm 0 �• r Addressa�e e City/Town tl. C, V, 4VV 4"lee, ✓ Si nature of su e"9re istered well drdler "Please print firtirily BOARD OF HEALTH C.OPV C f BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS Client: TARTAN INC Collection Date: 05/12/93 Mailing Address :P 0 BOX 1198 Date of Analysis :05/13/93 WEST CHATHAM MA 02669 Type of Supply: WELL Well Depth (FT) : 71 Telephone: Sample Location: 19 PERCIVAL LANE LAT. (DDMMSS) : Not Given BARNSTABLE LONG. (DDMMSS) : Not Given Collector: C STIEFEL Map/Parcel : Affiliation: BCHD Analytical Method: 502.1=1 , 502.2=2 , 503.1=3 , 504=4, 524 . 1=5, 524.2=6 , 502 .1/503=7 Contaminants Anal . Result MCL Detection Detected Meth. ug/1 ug/l Limits (ug/1) --------------------------------------------------------------------- Chloroform 2 2.1 0. 5 Only those compounds listed above were detected. Attached is a list of compounds for which this sample was analyzed. NOTE: Contaminant levels equal to or exceeding the Detection Limits are reported. MCL means Maximum Contaminant Level for EPA-regulated compounds . (ug/1 = micrograms per liter = Parts Per Billion) The Environmental Protection Agency has set Maximum Contaminant Levels (MCL) for the following compounds . This sample compares as follows: COMPOUND MCL (in PPB) Benzene 5.0 * level not exceeded * Carbon Tetrachloride 5. 0 * level not exceeded * 1 , 2-Dichloroethane 5.0 * level not exceeded * 1 , 1-Dichloroethene 7 . 0 * level not exceeded * 1 , 4-Dichlorobenzene 75 * level not exceeded * 1 , 1 , 1-Trichloroethane 200 * level not exceeded * Trichlor0 ethene 5. 0 * level not exceeded * Vinyl Chloride 2 .0 * level not exceeded * Comments or additional compounds found: + Thomas F. Bourne, Laboratory Director yA GAl�3l�tyE :6RIiJDET— PA I D( FL O W.. � 5E•PFl C:- TAtJ ,. hlSPoSAI PIT SEE SIDEMLL A ISM 5r rPC.A�1 OtJ �AGk �IErz� = '1c L 5161J S 'Wfi, l'� IQAL. t)z\/E I TOTAL DAII. -0N/ _ 3D T%E2�oLAT1oN ... Alt f'W 2XAW:.;OZLE V/E6T 8AiZ�`�TABLJE 1 : � I 'OS PETER;.. :. c f LA rS ... ,,,..S.ULLIVAN : f 29733 l SS/pfVA L I TF- 104 � P.v 10 e-_ IN✓. Ion P�tsrtx� $ram INV.' tN� GAL Ioo.B too•6 SeprIc 00 D IoID loe� : TA N to •v SAUD u_ SrQucry, s�T c ur . 14ALLR 6E �I`Zo 'Zoo6 30/15 LOE PEA ti ! yElyP� I Loc. TloN : I r LoT t P Gt'18 �GII Li~-', �� 4-D DATc—; �o l�lAT�e. o Wad pr�to � �A S owN N�ZEaN oMPL` S .wlrA Tub is o'rIt l ��i Gov .plait 1, 1,�' S C&Sl� IR 4131, P20Fla`,(OQAL •LAQ*D ill, I ►J lS Nor. .: F3 AZ) oil AN- l�JSTevti1EI�T' Su2Ue`f AI��. r�{ :. .oF�SE'TS �1IDUI�. tJiTj" �3E c��L �i1C ►4r:.E�; i u5�1� TO G `TA U-J'5N �Pt?oPE1Z'j 5 l rZv r u1= APPLIC„NT; r r +.4 r-A I L !! '..__i 1 I Iz . I _ r AA STD; � r BCD` A , - I i t 1 as I � i , t i 1 WOF PtTER $ULLIVAN , No:29733 Y I �.z.:;A . .;_r ( , r � �STEa r LO A1