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HomeMy WebLinkAbout1379 HYANNIS-BARNSTABLE ROAD - Health 1379 HY.-BARNS.RD:, BARNSTABLE': A;297-007 J z ' n I K C01MMONWEAL H OF MASSACH SETTS EXECUTT T OFFICE OF ENVIRONMENTAL AFFAIRS t DEPARTMENT OF ENVIRONMENTAIf PRE PNECYl M AP PARCEh '' O® f' V1,1N OF BARNSTABLE +� r W O .._. rxL.TH DEPTi. _ - TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: &in yl iAMA Owner's Name:Car l .lnit. .___� Owner's Address: c�a,nnis :3a rP��4� Q� moo- t Say Date of Inspection: Name of Inspector:(please print) Jzck Al. / Company Name: ft n✓;1&A 4 47spec4f0 k,.S Mailing Address: in aL�IR� "nd Telephone Number: OZ6q/ CERTIFICATION STATEMENT- I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my am a EP train' and experience in the proper function and maintenance of on site sewage disposal systems.I D � XP P Pe approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(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: Notes and Comments a R ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I r Page 2 of I 1 *� OFFICIAL INSPECTION FORD-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DMSPOSAL'SYS'TEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:i 79 Qr�rTiS — iRnN , !S 7 - isrM Owner: Date of inspection:• lot , Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D. A. System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. ., Comments: s B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section ., to be replaced or LL repaired The system,upon completion of the replacement or repair,as approved by oard of Health,will pass. , Answer yes,no or not determined(Y,N,ND}in the for the followin menu.If`blot determined'°please explain- The septic tank is metal and over 20 years old*or the tank(whether metal or not)is structinally unsound,exhibits substantial infiltration or ex tfution or failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as mved by the Board of Health. *A metal septic tank will pass inspection if it is stru ly sound,not leaking and if a Certificate of Compliance ' that the tank is less than 20 old is fable. indicating Y�caking ND explain Observation of sewage backup break out or l4lt static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro settled or uneven won box.System will pass inspection if(with approval of Board of Health): broken per$)arexqAaced obstructionis,umoved , :- distriiWcm box is leveled or replaced ' ND explain: The m required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass' n if(with approval of the Board of Health): a broken pipe(s)are replaced tww d obstruction is removed a ND explain: 2 Page 3 of 11 ' OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: fea e4 . Date of Inspection: D firofr C. Further Evaluation is Required by the Board of Health: Conditions exist which require farther evaluation by the Board of Health in order to det ine 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 3 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health afety and the environment: _ Cesspool or privy is within 50 feet of a surface water µ _ Cesspool or privy is within 50 feet of a bordering vegetated land or a salt marsh 2. System will fail unless the Board of Health(an ublic Water Supplier,if any)determines that the system is functioning in a manner that protects public health,safety and environment- The The system has aseptic tank and soil sorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ce water supply- - The system has a septic tank an AS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septi 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 passe f the well water analysis,performed at a DEP certified laboratory,for coiiform bacteria and volatil organic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria a triggered.A copy of the analysis must be attached to this form. '4 3. Oth " u w � t 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D o&4L_SWTEM INSPECTION FORM r. PART:A- CERTIFIECA•I 16N(cowed) Property Address: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for aII'inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool e to an overloaded or. waters du Discharge or ponding of effluent to the surface of the ground or surface . clogged SAS or cesspool Static liquid level in the distribution lox 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 thau'h day flow ed or obstructed s .Number e to clogged ) ' the last year NOT du P� ore than 4 times in y � — � Required P��m . of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. PeAny 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 cofform bacteria and volatile organic_coatpimads indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal<to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to.this form.) (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: To be considered a large system'the system mast serve a facility with a design fiow of 10,000 ggd to 15,008 You must indicate either"ye!?,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 r s , the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=rWPA)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 15304.The system owner should contact the appropriate regional office of the Department- 4 Page 5 of 11 a , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . r Property Address: /J7 Q '�✓"r'� "`' Owner: ado r Date of Inspection: O D� Check if the following have been done You must indicate"Yes"or"no"as to each of the following: Yes No f f _ 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 2` — 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? by _ 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 tenance of subsurface sewage disposal systems?- The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. J Determined in the field(if any of the failure criteria related to Part C is of issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)l 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION N' Property Address: /1, 2 9 Owner: Date of Inspection: td _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): ' Number of bedrooms(actualj: DESIGN flow based on 310 CMR 15103(foi example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage der or no) :IVO Is laundry on a separate sewage system(yes or no): Vo[if yes separate inspection required] " Laundry system inspected(yes or no): Seasonal use: es or no):/� (Y , Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(Yes or no):AD Last date of occupancy:c=G�Li COMMERCIAL/INDUSTRIAL Type of establishment: u. Design flow(based on 310 CMR 15.203): Qpd Basis of design flow(seats/persons/ tc.): Grease trap present(Yes or no): , , .. Industrial waste holding tank p ent(yes or no): Non-sanitary waste dischar to the Title 5 system(yes or no): ; Water meter readings,i vailable: Last date of occup y/use: OTHER(d ribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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 infoririation:" 6 .�Q Were sewage odors detected when arriving at the site(yes or no): 6 i page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) _ � �Property Address: /3 GLI ��„ Owner: Wi 9'4,VZ5 Date of Inspection: t BUILDING SEWER(locate on site plan) a _ Depth below grade: _ Materials of construction:,cast iron _Ar 40 PVC_other(explain): ' Distance from private water supply well or suction line: etc. r venting,evidence of leakage, ): ,. Comments(on condition of�omu, n g, eakag SEPTIC TANK: (locate on site plan) Depth below grade: t Material of construction: &concrete____metal�fiberolass_polyethylene _other(explam' • (attach a copy of If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): certificate) Dimensions: I SZb / Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: c3 Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet to r baffle: I y How were dimensions determined:- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,Iiquid levels „ as relatedto outlet invert,evidence of I e,etc.): - IS I ' •'fAP e GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete I fiberglass polyethylene`other (explain): Dimensions: Scum thickness: Distance from top of scum t op of outlet tee or baffle: Distance from bottom of s to bottom of outlet tee or baffle: Date of last pumping: Comments(on pump recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet t ert,evidence of leakage,etc.): ' 7 Y Page 8 of I! h OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAINT C SYSTEM INFORMATION(continued) Property Address:/ Vrt5-"4? E74 Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank musZpuerd of inspection)(locate on site plan) Depth below grade:Material of construction: concrete mePolyethylene other(explain): Dimensions: Capacity: a11 Design Flow: ons/day a Alarm present(yes or no): Alarm level: Al in working order(yes or no): 3 Date of last pumping: Comments(condition alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_4eyGY1 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage Ip or 6 �out of box,etc.): P t a A t`Tfc,c i w n tjA PUMP CHAMBER: (locate on site pl Pumps in working order(yes or no y ` Alarms in working order(yes ): , Comments(note condin pump chamber,condition of pumps and appurtenances,etc.): • 0 Page 9 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l - Owner. /GK Date of Inspection: 6 lr- SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: r. Type leaching pits,number._ _leaching chambers,number teaching 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,,dam soil,condition of vegetation, etc.): 7- e Ar CESSPOOLS: (cesspool must be pumped as of inspection)(locate on site plan) Number and configuration: a Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: - Indication of groundw r inflow(yes or no): Comments(note co tion of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.): PRIVY: (locate on site Materials of constru n: Dimensions: k Depth of soli Comments to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / rns` �• R40 x Owner: W ; ,rmegsg Date of Inspection• SKETCH OF SEWAGE DISPOSAL SYSTEM "' Provide a sketch of the sewage disposal system including ties to at lust two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. e , Vj 1 E 3 , �(Ovv\— ]A e ♦Page 11 of 11 a OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L3 Zg r a,—.a s Owner. t e Date of Inspection, D I toy SITE EXAM Slope �5 Surface water Check cellarQS Shallow wells OJQ Estimated depth to ground water-.25:-feet r 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: Observed site(abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) iY Accessed USGS database-explain: You must d scribe how you established the high ground water elevation: W. .. r 1l J No. O / < }, Fee JD 1 e THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYicatiou for Mtgaal *potem Con!Aructiou Permit apT 60) Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. q3,Q,kowner's Name,Addre �V Assessor's Map/Parcel ®® Installer's Name Address,and Tel No. YY�� tT Designer's Name,Address and Tel.No. � r Type of Building: Dwelling No.of Bedrooms��� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alte itions(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions aTitle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is a is Board Healt Signed Date-7 -3 IQ Application Approved by Date Application Disapproved for the following reasons Permit No. 9 Date Issued '- 3 No./ / O "7 '/ Fee J 01 1. _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: sYei PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for Mi-qpo!6ar *pztetn Construction 30ermit Application for a Permit to Construct( )Repair( r')Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ' 3 7 ¢+N It I,�1 w��';N Te No. Assessor's Map/Parcel on (/ '� + Installer's Nam Address,[anndf�T(eell.No. - Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i.._ Nature of Repairs or Alterations Answer when applicable) M Date last inspected: r �` Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions . Title 5 of the Environmental Code and not to place the system in operation until a Certifi- r Cate of Compliance has been is is Board Heal i Signed Date 4 Application Approved by Date 7'30— q Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO C ,that the Sewage Disposal SXstem Constructed( )Repaired( ✓)Upgraded( ) Abandoned )by at I l-q5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _?t dated Installer Designer The issuance of this peMut shall not _gconstrued as a guarantee that the sys m will function as designed Date Inspect r No.�l O '� �l/ --------------------- —---- Fee d1�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS lwigozal *p5tem Construction Permit Permission is hereby rante to Cons ct( air(✓U rade( ( bandon( System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be c mpleted within three years of the date of thi ermit. �` Date: / —�� / Approved b C ,�/ n 7/98 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, hereby certify thZthe application for disposal`works construction permit signed by me dated Tl yU ^�g , concerning the property located at( meets all of the f I following criteria: w4 e There are no wetlands located within 100 feet of the proposed soil absorption system. O There are no private wells'located within 150 feet of the proposed septic system. • There is no increase in flow and/or change in use proposed: • There are no variances requested or needed. • If there are any wetlands located within 250 feet of the proposed soil absorption system;the ' observed groundwater table is 14 feet or greater below the bottom of the leaching facility. • I understand that the attached Title V Calculation Chart may only be used for the design of a septic system if the existing naturally occurring soil is classified as Class I(sand or loamy sand) in the most hydraulically restrictive layer included within the five foot zone beneath the proposed soil abs system. If the soil conditions are not Class I within this above described zone,a pr ssional en 'neer or registered sanitarian is required. SIGNE A DATE: . LICEN PTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Please complete the following: n y A)Elevation at top of ground in the location of the proposed soil absorption system " l B)Elevation of groundwater [Attach a sketch plan of the proposed system. Also if the licensed installer possesses a certified plot plan,this plan should be submitted]. q:health folder:Cert2 r� ' ^�► c __ _ �� - ,.��-t -� ,�/ o �C �� ��� C� �� " � �r - i w SAW rsaux Z MASS Home: Departments:Assessors Division: Property Assessment Search Results fye 1379HY N IS— NSTA LEE —ROAD Owner: TRIPP, CARLA M Property Sket h Legend Map/Parcel/Parcel Extension 297 /007/ Mailing Address ; TRIPP, CARLA M 1379 OLD HYANNIS RD P BARNSTABLE, MA. 02630 N. 3• 2005 Assessed Values: Appraised Value Assessed Value Building Value: $163,100 $163,100 Extra Features: $4,200 $4,200 Outbuildings: $400 $400 Land Value: $ 128,100 $ 128,100 interactive Property Map: ap requires Plug in: Totals:$295,800 $295,800 1 have visited the maps before s � . First time users Show Me The Map Click Here April 2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: TRIPP, CARLA M 5/15/1990 :7159/271 $1 TRIPP, ROBERT M &CARLA M 2130/205 $0 BLAKELY, GEORGE W 5150/262 $0 BLAKELY, GEROGE W 5693/155 $0 y 2005 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation) Land Bank Tax $53.69 Town Fire District Rates Other Rates $6.05 Barnstable-Residential $2.12 Land Bank 3%of Town' Barnstable-Commercial $2.80 Barnstable FD Tax(Residential) $627.10 C.O.M.M.-All Classes $1.01 Cotuit FD-All Classes $1.28 Town Tax(Residential) $1,789.59 Hyannis-Residential $1.52 Hyannis-Commercial $2.39 W Barnstable-Residential $1.44 W Barnstable-Commercial $2.10 Total: $2,470.38 Due to rounding differences these values may vary Land and Building Information Land y, Building Lot Size(Acres) 0.23 Year Built 1967 Appraised Value $ 128,100 Living Area 1755 Assessed Value $128,100 Replacement Cost$196,529 Depreciation 17 Building Value 163,100 Construction Details Style Cape Cod Interior Floors Hardwood Model Residential Interior Walls Drywall Grade Average Plus Heat Fuel Oil Stories 1 1/2 Stories Heat Type Hot Water Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip Bedrooms 4 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 2 Bathrooms Total Rooms 7 Rooms Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value BRR Bsmt Rec Room 400 $ 1,700 $ 1,700 SHED Shed 64 $400 $400 FPL2 Fireplace 1 $2,500 $2,500 Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) . II i 3 ���;/ 02 I . i 6 -5 ',cg kf TO OF BARN LE -11 , o LOCATIONoiq nM SEWAGE # -I VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) c�`6�'1/�k, (l QA (size) 10 X 30 NO.OF BEDROOMS 1 .;" I i '\ BUILDER OR O -� R PERMIT DATE: ";-1 COMPLIANCE DATE: I C� 0 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 . n site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist n 300 feet of leaching facility) Feet Furiu'shed by 1 .� 3`` � , ' / � �. D .' 1� �✓ / t � �w � � � � ��/ 'V � � ._.__ � � , } PEA ��a �.l i.' �i j .,� �, :;' +� ,�_ �. {. � � � �