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HomeMy WebLinkAbout0042 MARBLE ROAD - Health Marble Road' Barnstable A = 316 032 s • _ . TOWN OF BARNSTABLE LOCATION L a Ali f b`-e 2agd' SEWAGE# VILLAGE C 0n Sll b/t ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. a-lc t1� � SEPTIC TANK CAPACITY 000 LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER �`�co sah PERMIT DATE: COMPLIANCE DAB Separation Distance Between the: . Maximum Adjusted Groundwater Table to the 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 � J�►� l.�`�S 6 42 Marble Road,Bamstable,MA Cad M&Regina P Jacobson owner 0 fs Name Ramstable _—.... m1Dona°Oe o ,. _ regmred for every __.4 MA 02630 06/15/2015 _ r ow. cirya— Sffi ro COEe Dateoilirspeoiun.''�""_ D.System Information(cost) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,inU.ding des to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate w; enters the water supply ente the building.Check one of the boxes below: ., hand-sketch in the area below ❑drawing attached separately _ 1 — DWEt J � I t\ �\v� 91 ; Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C 42 Marble Road, Barnstable, MA P Property Address Carl M &Regina P Jacobson rr+ Owner - Owner's Name + q} information is required for every Barnstable MA 02630- 06/15/2016 x page. City/Town State Zip Code. Date of Inspection -� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ' I on the computer, - l use only the tab 1. Inspector: key to move your cursor-do not REID C. ELLIS use the return key. Name of Inspector - ELLIS BROTHERS CONSTRUCTION - Company Name r 23 ENTERPRISE ROAD Company Address YARMOUTH PORT MA 02675 Cityrrown State . Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the- information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: /Passes' ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspect 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 U report to the appropriate regional office of the DEP. The original should be sent to the system owner �ti and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form z Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Marble Road, Barnstable, MA Property Address Carl M &Regina P Jacobson Owner Owner's Name information is every Barnstable ' required for eve MA 02630 .: 06/15/2016 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: WOel have not foun ranynformation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) S y Passes:stem Conditional) y , ❑ One or more system components asdesci ibed in the"Conditional Pass"section need to be replaced or repaired. The system, upon cc mpletion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determin "(Y, N, ND)for the following statements. If"not determined," please explain.- The septic tank is metal and over 20 years old or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfi tration 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 sourid,'not leaking and if.a Certificate of Compliance indicating that the tank is less thar 120 years old is available. ❑ Y• Nr ❑ ND (Explain,b low): r: t5ins•3/13 t Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Dis osal S stem.F - 9 P Y orm Not for Voluntary Assessments 42 Marble Road, Barnstable, MA Property Address Carl M & Regina P Jacobson Owner Owner's Name information is required for every Barnstable MA 02630 06/15/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont:) ❑ Pump Chamber pumps/alarms not operations- I. ystem will pass with Board of Health approval if pumps/alarms are repaired. PP B) System Conditionally Passes (cont.):. ❑ Observation of sewage backup or break out or h gh static water level in the distribution box due to broken or obstructed pipe(s)or due to a-brokE 1, settled or uneven distribution box_ System will pass inspection if(with approval of Board of Hea th): - ❑ broken pipe(s)are replaced ❑ Y ❑ N . ❑ ND (Explain below): ❑ obstruction is removed' - ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):3 ❑ 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 t1 ie Board of Health):. El are replaced ❑ Y ❑ N ❑ ND (Explain below):y ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 1 C) Further Evaluation is Required b the Board of Health: ff.- ❑ Conditions exist which require furth r evaluation by the Board of Health in order to determine if the system is failing to protect publi health, safety or the environment.' ` 1_1. System will pass unless Boarc of Health determines in accordance with 310 CMR '15.303(1)(b)that the system is no functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 0 feet of a surface water ❑. Cesspool or privy is within 0 feet of a bordering vegetated P Y g wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for p y o Voluntary Assessments , 42 Marble Road, Barnstable, MA Property Address Carl M &Regina P Jacobson Owner Owner's Name information is Barnstable required for every MA 02630 06/15l2016 page. Cltylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of�/ealth (and Public Water Supplier, if any) determines that the system is functionii ig in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil bsorption system (SAS)and the SAS is within 100 feet of a surface water supply or tribut iry to a surface water supply. ,❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a"septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " **This system passes if the well water analysi , 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 must be attached to this form. 3. Other: System Failure Criteria Applicable to All Systems:. You must indicate"Yes".'or"No"to each of the following for all inspections: Yes No ❑ I 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 '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17. Commonwealth of Massachusetts y Title 5 Official Ins action ;Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments' 42 Marble Road, Barnstable,°MA Property Address Carl M &Regina P Jacobson. Owner Owner's Name,.a information is Barnstable ` required for every MA 02630 �06/15/2016f ' page. City/Town State _ Zip Code • Date of Inspection" B. Certific ation' (Cont.)* Yes No u V_ 0�_-,_ a i Required pumping more than 4 times in the last year NOT due to clogged or`, i. obstructed pipe(s). Numtierof times`pumped; Any portion of the SAS,' cesspool or"privy is`belowhigh ground water elevation_, Any portion of cesspool or privy is within 100 feet of a,surface water supply or^ 4 tributary to a surface water supply. f 0 Any°portion,of a cesspool or privy is within a Zone 1 of a public well. :4 ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. 10 Any portion of a cesspool or privy is less than 100 feet butgreater 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- ' 10,0009pd• The system fails.1,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 Bo d of Health to determine what will be necessary to correct the failure. E) Large Systems:' To be considered a large system he 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. s �. Yes No z the system is within 400 feet of a surtace dunking water supply 0 ❑' the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitroge Sensitive area (Interim Wellhead Protection- Area—IWPA)"or,a mapped Zone 11 of a public,watersupply well If ou,fiave answered"yes"to an M f' t - Y y y question in Section the systemis 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 r failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The syst owner should contact the appropriate. regional office of the Department. 3 i ' S f t5ins•3M3 } Title 5 Official Inspection Forth:Subsurface Sewage Disposal^ 9 p I System.-Page 5 of 17 . w r - e e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments d 42 Marble Road, Barnstable, MA Property Address Carl M &Regina P Jacobson Owner Owner's Name information is ' required for every Barnstable MA" 02630 06/15/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following.- Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health+ ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of / this inspection? LEI{ ❑ 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? 1� ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened; and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,-depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. .❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 3 d Number of bedrooms(design): Number of bedrooms.(actual): p d DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33 k ' t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page' of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Marble Road, Barnstable, MA Property Address Carl M & Regina P Jacobson ` Owner Owner's Name information is required for every Barnstable MA 02630 06/15/2016 page. Cityrrown State Zip Code Date of Inspection., D. System Information Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes, [''� o Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected?, ❑ Yes o Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: j Sump pump? El Yes No Last date of occupancy: C��'�►�Tbf� yr1�l Date Commercial/Industrial Flow Conditions: ' �/11 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 resent? Yes No 9 p ❑ ❑ Non-sanitary waste discharged to the Title 5 syst m? El Yes El No Water meter readings, if available: t5ins•3113 ale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 ,.0 42 Marble Road, Barnstable, MA' - Property Address Carl M & Regina P Jacobson Owner ` information is Owner's Name - required for every Barnstable MA 026W 06/15/2016 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records:. Source of information: IV 16 Was system pumped as part of the inspection? k Yes ❑ :No If yes, volume pumped: gallons How was quantity pumped determined? r / . Reason for pumping: � '� Type of yytem: Septic tank,.distribution box, soil absorption system ❑ Single cesspool ❑, Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under'contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 8 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Marble Road, Barnstable, MA Property Address Carl M & Regina P Jacobson Owner Owners Name information is required for every Barnstable MA 02630 06/15/2016 , page. CitylTown State Zip Code Date of Inspection D. System Information'(cont.) Approximate age of all components, date installed (if known)and source of information: � . Were sewage odors detec when arriving at the site? _ ' � ❑ Yes No Building Sewer(locate on site plan): 3-5 e Depth below grade:,., feet Material of construction: ❑ cast iron 46 PVC other(explain), Distance from private watersupply well or suction line:D —feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: t '' ` -' � feet Material`of construction: concrete •❑ metal ❑fiberglass ❑ polyethylene'y ❑ other(explain) eA • J If tank is m al, list age: ' years rteofis age confirmed by a CertificCompliance?`(a t ch a copy of.certificate)11 El Yes ❑ No Dimensions: gAr i 1i 4 Sludge depth: t5ins•3/73 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 / • q , x> Commonwealth of Massachusetts Title 5 Official Inspection Form Q Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w., 42 Marble Road, Barnstable, MA Property Address Carl M & Regina P Jacobson Owner Owner's Name information is required for every Barnstable MA 02630 06/15/2016 page. Cltylrown State Zip Code Date of Inspection D. System Information (cont-) Septic Tank(cont_) Distance from top of sludge to bottom of outlet tee or baffle 2-7 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 How were dimensions determined? � Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outl t invert, evidence of leakage, etc.): WAf 'Wz po"ne Grease+Trap (locate on site plan): ' -11 y. Depth below grade:: feet Material of construction: ❑ concrete :❑ metal ❑fi erglass ❑ polyeth lene Y El other(explain): - � �. � • it Dimensions: I -Scum thickness Distance from top of scum to top of outlet tee r baffle Distance from bottom of scum to bottom'of out et tee or baffle Date of last pumping: y Date - t5ins•313 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Marble Road, Barnstable, MA Property Address " Carl M & Regina P Jacobson Owner Owner's Name information is required for every Barnstable MA 02630 06/15/2016 page. City/Town State Zip Code . Date of Inspection D. System Information (cont.) ' Comments(on pumping recommendations inl�ndoutlet 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 El metal ❑fiberc lass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: • gallons Design Flow: t 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, c.): , *Attach copy of current pumping contract(required . Is copy attached? ❑ Yes ❑ No t5ins•Wl3 'Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ".� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Marble Road, Barnstable, MA Property Address Carl M &Regina P Jacobson Owner owner's Name information is required for every Barnstable MA 02630 06/15/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert � Comments(note if box is level and distribution to outlets equal, any evidence of suis carryover, any evidence of leakage into or out of box, etc.): i 1S, -sty' A 744• Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No* ❑ . Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, cor dition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass., Soil Absorption System'(SAS) (locate on site plan, excavation not required): If SAS'not located, explain why: f t5ins•3N3 r _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 ' Commonwealth of Massachusetts t Title 5 Official Inspection. Form o Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 42 Marble Road, Barnstable, MA ' Property Address Carl M & Regina P Jacobson Owner Owners Name information is required for every Barnstable MA 02630 06/15/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) fill Type. ❑ leaching pits number: FA Y 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 Cesspools(cesspool must be pumped as �bfspection) (locate on site plan):. Number and configuration Depth—top of liquid to inlet invert , Depth of solids layer Depth of scum layer , Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ' ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Marble Road, Barnstable, MA » Property Address Carl M & Regina P Jacobson Owner Owner's Name information is required for every Barnstable MA 02630 06/15/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) / Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): s " Materials of construction: Dimensions Depth of solids " Comments (note condition of soil, signs of by(raulic failure, level of ponding, condition of vegetation, etc.): (Sins 3113 Title 5 Official Inspection Form:Subsurface Sewa a Disposal System•Page 1 9 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z Y ry s ents 42 Marble Road, Barnstable, MA Property Address Carl M &Regina P Jacobson Owner Owner's Name information equir for is every Barnstable required for eve MA 02630 06/15/2016 page. CitylTown State Zip Code ; Date of Inspection D. System Information (cont.) a Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks- Locate all wells within 100 feet. Locate 7hand-sketch public water supply enters the building. Check one of the boxes below:in the area below ❑ drawing attached separately 11 o� ,CI E_ Atop _qq.3�' I , 1 ' � p s 4dj� 0 t5ins•3/13 Titles official Inspection Form:Subsurface Sewage Dispose l'S 1.ystem•Page 15 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments Qi 42 Marble Road,Barnstable, MA Property Address Carl M & Regina R Jacobson „ Owner Owner's Name information is required for every Barnstable MA 02630 06/15/2016 page, Cityrrown State ` Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ .Surface water . `7 ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: �" �. 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: .r ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: 13 You must describe how you established the high ground water elevation: e4�,�'9 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3,113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form' is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 5 % ' 42 Marble Road, Barnstable, MA Property Address , Carl M &Regina P Jacobson Owner Owner's Name information is required for every Barnstable MA 02630 06/15/2016 page. City/Town State Zip Code Date of Inspection E. Re ort Completeness Checklist Re Summary: A, B, C, D, or E checked - I spection Summary D(System Failure Criteria Applicable"to All Systems) completed stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or.attached in separate file ' 6 r 4 , tr t5ins•313 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17, of 17 TOWN OF BARNSTABLE LOCATIONn� �� SEWAGE #moo c/a ,VILLAGE lv ST q-� le ASSESSOR'S MAP & LOT. / 03Z-) z,INSTALLER'S NAME&PHONE NOA/,siy, SEPTIC TANK CAPACITY S T LEACHING FACILITY: NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:�� � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 l 2 ' c / F D (Fee- 6,e A No. 0 3� `O r s: Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for Die;poal bpelem Conotruction Permit Application for a Permit to Construct( . )Repair(--YUpgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or o. Owner's Name,Address and Tel.No. Assessor s Map/Parcel • GU "t► mA�v 3/6-- r�3 Installer's Name,Address,and Tel.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 3 gallons per day. Calculated daily flow -S S gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank o tv o Type of S.A.S. (Z-) s�oo Description of Soil Nature of Repairs or Alterations(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 of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss this Board of Health. Signed Date Application Approved 6y J - Date YT 2 2 ©? Application Disapproved ror the following reasons Permit No. 2 CO 3-404 Date Issued �/ 2 2`O 3 q No. c ` 1 Fee `T HE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: a Yes PUBLIC HEALTH DIVISION -TOWN`C�F BARNSTABLE, MASSACHUSETTS 2pprication for 33igpool *pztem Con!5tructiou Permit Application for a Permit to Construct( )Repair(,-)-Vpgr�de( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. , Owner's Name,Address and Tel.No. Z{� f32h�L� l� Assess o s M p/Parcel c 'o?v Installer's Name,Address,and.Tel.No. Designer's Name,Address and Tel.No. ,e /Z r Go YW!!/1 F L=y C 2 S-oF > 7s- 13 Ga � � / S��- 7-3 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 Of gallons per day. Calculated daily flow -.S l gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank N"k � T / O d O Type of S.A.S. Q (-oo C/f si A., �t c Description of Soil Nature of Repairs or Alterations(Answer when applicable) /. /a n )e r�- r,2 eo S v or- y ,.Pate 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 of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued-bW this Board of Health. __----- Signed-'J.�''" i �'�' Date Application Approved by Date 2 2-G Application Disapproved or the following reasons Permit No. ? (-0 3- (Oc( Date Issued bl 2 2 -U?' --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by A w_ c '4/ e-e s T at 4V r-7 0.0 s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Zo 03-L/o dated - ?.2 - 03 Installer l_`7 !Z- /-/ Designer /�,a it it /'1'l< sie' The issuance of this permit shall not be construed as a guarantee that the system nation as igned.,� I/ Date -7 4 , Inspector t "Z f --------------------------------------- No. 2 _ !4 G Fee 0— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Mi!5pogar bpgtem Conotruction Permit Permission is hereby granted to Construct( )Repair( -�_grade( )Abandon( ) 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 completed within three years of the date of this permit Date: 2 2-d 3 Approved by TOWN OF BARNSTABLE LOCATION -1 7 - { nl SEWAGE VILLAGE A / ASSESSOR'S MAP &LOTS/i< 03-'-)- INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY ' T l /3 LEACHING FACILITY: (type (size) -5�( X NO.OF BEDROOMS _ BUILDER OR OWNER COMPLIANCE DATE: 3 PERMIT DATE:_, Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching FaEility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by . � N J" A TOWN OF BARNSTABLE LOCATION _ //l av/7�2 krA- ) SEWAGE # VILLAGEi4(LiY-�t-4�� ASSESSOR'S MAP,& LOT INSTALLER'S NAME & PHONE NO. �[ L 1�tv1/� SEPTIC TANK CAPACITYZcZ LEACHING FACILITY:(type) 'NO. OF BEDROOMS PRIVATE WELL OR PYIGIC_ WA R BUILDER OR OWNER DATE PERMIT ISSUED: j DATE COMPLIANCE ISSUED: . VARIANCE GRANTED: Yes No L t; ( rt3o�C New ��'°�✓� a FRis �� �► +..nC'► SHE COMMONWEALTH OF MASSACHUSETTS HBO A R D OF HEALTH Qate TOWN OF BARNSTABLE , pphration for Diripwi a1 Wnrk,i C omitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (V5"an Individual Sewage Disposal System at: .................. -... Y b_� ../�-:►�--•---........_..... w e..... 4 ............................................... Lo on-Address or Lot No. Cl6.lM1......... --------------------•------- -----------------�� l dL........----------•---- Owner Addr -----------•-----.r� -A,...� P--------------------------------------- ----------- .Q.-:...a ..fess G-----.--..-A1.�..-- Installer Address Type of Building Size Lot.................... Sq. feet Dwelling—No. of Bedrooms.--- ;-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building --------------------_----. No. of persons------------.--------------. Showers ( ) — Cafeteria ( ) Pi Other fixtures --------------- ------------- W Design Flow........45--..�....................gallons per person per day. Total daily flow...... .......................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter--.-----.-----_ Depth................ x Disposal:Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. e � 3 Seepage Pit No.------ ............. Diameter--- -Q.------- Depth below inlet----j�a........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ') Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit---------..--------- Depth to ground water........--..........--.. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-....................... ..................-................................................................................................................................=........ 0 Description of Soil........................................................................................................................................................................ x x ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-- U Nature of Repair or Alterations—Answer when applicable_ZJ7_-- ......L 4 �T.......... ----------------------Ul �_ � '�`� t7 -t -: ' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the bo d of hoth. Signe ---------- ...... ----- . ....... .......... ................. ../ ..`-........ ..:....f Application Approved By ..... .. ... .�... ........... .... ..... .. ..... . �..... f. .. Application Disapproved for the following reaso -" .....: ....... ..... Dare Permit No. Issued ....... .. ............ Dac .. ... ... ..... ... ............... e #�F.ne'�'�'^�i.1✓�y.ii��.d 14'1RSi-.=:��^7""'a'k.�'Yi:'�t'1.:�1✓e�J'�'.�� (f.r.'� ..*ter a�l�l 1 •� 'K]se^wi'M� s}+.�..� +ItYMi4���j1� :..' '•: ��rt'l +.wy������•�.}.. �, .. _... f:. ��,L J � "!4'� "�»ye a�.�1�4 J&w.✓b �i 4Air" �,+.4�k1.s�. 1'S.+�� #��A. Jr+sNilWt'+L+4�.•EJ4'A.rt..J�..•=Sy.�Nj4+W+t7✓.[sw"'.'pjf''•+�.wap.. i �� T• �^�4 j , 03� ............ No. j :...- .. F�$. THE COMMONWEALTH OF MASSACHUSETTS �(# 1 BOARD OF HEALTH TOWN OF BARNSTABLE , pphration for Diripwial Midw Towitrurtiun f v*rntit Application is hereby made for a Permit to Construct ( ) or Repair (�,/) an Individual Sewage Disposal System at:f` f 2 t ..............................................-.................................................. = ,.-------------•----•-••--•----•-------•---------•--...--•---.....------•-- ��''� Lo�rition-Address or Lot No. i.......!i1•J k s`', i� `... -. ... ................ owl er t Address Installer Address UType of Building Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms.... ...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures ..................................................................................................................................................... W Design Flow........ ....................gallons per person per day. Total daily flow..... n.......................gallons. WSeptic Tank—Liquid capacity------------gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No of........... Diameter---_�`.�? ....... Depth below inlet....Z2........... 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........................ �X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --••-------•.....................•-•---•••-•----•-••---••••-•-•-•••-••-••-••-......•......................................................................... 0 Description of Soil........................................................................................................................................................................ W U ••••••••••-•••••••••---•.........-•••••--•-••-•......-••••••-••••-•-•-•-----•----...••••••••------•-••••-••-•-----.....-•-••------•••••••-••-•-...-••••••••••••••-•....................•-••......_-•-••- W x ••• ••-•---•-------- ---------------------••---••--------------------•------------------••------------••--...---------....-----...••----•--•--•--•-•-••--•-------•--•--•---•--••••......----------•-••. U Nature of Repairs or Alterations—Answer when applicable_. .fit_.____(..(-VID....(.>--. �_�_�- 'l T.......... .................................—'' � /<t,r. r?/;f !! t r T Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed�...:�+^'"/ r , .:. .-.- ,.......:/ j, ?{t — .:......-.� ,.. ---- '` `..yam.... .._:.... ........................................ !"J Drce Application Approved By ... . 1. 2: ....:..........t ..........�.�.. � / �...........:�.............. .. C ,� e......-..`.../ Application Disapproved for the following reason. ................ . ... .................................................................................................. ................... .... ..-..-.....-... ..................-..� �!:........:........................................................................................ ........ ---. .......Dace �. Permit No. ......../ .......... ...0 ..-.-.......... Issued -..-... �?_......J...... -`?. ... � - Dace / v THE COMMONWEALTH OF MASSACHUSETTS,, BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Tompli? nve THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by _......................_.. F ..1 -P F_- ....`.: ..--...-......--..............----------*......-------................ �->' Ir AIL%.;.c.. *� .r.ia.fJ............ . YIN( h-(.�>.............. has been installed in accordance with the provisions of TITLE . f;The StatjEA onmental Code as described in the application for Disposal Works Construction Permit No. t.6 �,/I dated ......._.........--_...................._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON STRUS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspector -.-:_... ( l f / DATE.......... - .r.,X-l.. -r...._k-..:I t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��� TOWN OF BARNSTABLE No.../;�,..r..�..... FEE----�..--•-•---•- Rupuuat Vorkii �u�tutrrtiunrrmit Permission is hereby granted - ��7...l........ ! 71 to Construct ( ) or Repair ( t.--) an Individual Sewage Disposal System at No. -;1`,............................................r�:'c ...r.......---•--l- .....rid. c- •-----•-..-------•-- . ... ,,,— Street (M-IH �. ./.........t../�.r•�-'' as shown on the applicati�/Z/ 'for Disposal Works ConstructionPermit No._._v __.....� Dated�____ i �• .�,..-• Board of Hcalth DATE...... --------- ................................................... FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS 6 BOARD OF HEALTH Application is Areby made for a Permit to Construct or Repair an Individual Sewage Disposal Ins er Address Type of Buildi 3_15,0 Sq. feet P-1 Other fixtures . .,�Total leaching are, Z Other Distribution box ( ) Dosing tank ( ) rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... DI/)ep h to ground water--------_-------------- ^ ' g�-_-_-. . . The undersigned agrees to install the uforcdcscribed Individual Sewage Disposal System in accordance with the provisions of Article XIof the State Sanitary Code—The undersigned further agrees not mplace the system in operation until u Certificate o6 Compliance has bee ,p Issued by the board of hWth. Sign$�....:------^� ---------- ' ' ' ----.. '-^^lic--- Approved B'_ '---'----���---------'- ----------------- ~ a^ --- ^ Application Disapproved for the following reasons:................................................................................................................ . -__-__--'-_--_'-_.--___---_______---___'.---'___''-'--_._-.---_-_---_--_---.7--- ` Date Permit No � o&� -------------'^'-'''---''--'---' ''''''' '' '' ' -' '-- - No------ ..... F��...° .....�4...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH A -.. ' ................OF.... Application for Uiiipniia1 Works Tomitrurtiort Vrrmit Application is h ireby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Sys at: ,/o Aj p- / t - = A'' - .r ---•--......... -- - •-- Location- ddress ®. or Lot No.) Yam......_... ' Owner r Address W { t � ..... ............................................Address...............------...... ...... Ins er v UType of Buildin �ize Lot____ __ `!' ' __.Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons....................... . Showers — Cafeteria � Other fixtures ---- -----------------------------------------------.................................................. ---------------------------------- W Design Flow........................ ...��}._._..__gallons per person per day. Total daily flow____.__.._. __��` _-_--.-_____--gallons. t4 Septic Tank Liquid capacity_- ' gallons Length................ Width-----._.-------- Diameter--------------.. Depth-..-------_----- Disposal Trench— o..................... Width......_... ... Totaingth� ....._...._..... Total leaching area....................sq. ft. Seepage Pit No_____ ___________ Diameter/-•CC�___.f........ ep bZo'w et.__.P'........... Total leaching area___,JA.'sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--__-_..__________--.--- f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Dep h to ground water__-..._.-_------__-_---- ------------------ D Description of Soil______________________ e `er --------_ J -- ---`-t°` "? ' �:....f. ----------------------- ®`°�------ --------- ---------------------------- "� 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 Article XI 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. Sign d----` €• f`�--...fta- Application Approved B , Date A PP PP Y Date Application Disapproved`for the following reasons---------------•-------------------------------•-----------------------------------------------------------..... •--•--•--•-------------•----------•----------------------•-----•-•-----•----------•----•----------------•..----•------------------------------------------------------------------------------------•---- Date PermitNo........................................................ Issued.--- - --............... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r.................OF.... �.1�•!t� k ...:.... ........:............................ (Irdif iratr of Tomptiaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4'�or Repaired ( ) by... '� � '1?s en, 11 z.e_ l_ ------------------•----- c Inst to - has been installed in accordance with the provisions of Article Y>J of The State Sanitary C/ARANTEE s d�ribed in the application for Disposal Works Construction Permit No------------ _.?............... dated------ . '_ _.__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A C THAT THE SYSTEM WILL F NCTION SATISFACTORY. 1! 11"'? DATE---------- m .................................... Inspector _ _. _ s; t ----•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH + _3 ..... a.............O F.......... No. -=j.............• FEE. •�is��a.��t1 lark, Cn�tt��r�trti>�t� rruti� ., ' Permission is hereby granted------------ ° :. �.?r t z : n' �?_&---------------• - •-------•,•------- to. Constru f ( or Repair} ) an Ind' idual,Sjew ge Dispel Syste rt at Street / as shown on the application for Disposal Works Construction Permit �N' 0 l __.____ Dated.J;//4 _._. ....._.__ • �. ; !° 11 DATE.....=----- ........................... - h ��,'o d _ _ / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ,. .., .. ,.. ,,. ,.�. .�,�Y.. 9w ua.¢._.y{�4YI6/ffiiHuYWA1'Iak`6 'TS41 YY••' ...•"•` _.wsqyY•••.•••- _ _ _ :@7Ai&1W141tl1.?' b 64"' ytlWiY.JI .G- GY+x.1YJs4i8{v`'SLti$i 1➢ C a 19 ' �A ASSESSORS MAP : SIG o NOT ES: �T 1�1 � E LOGS sy PARCEL : 0 )" , 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH : 17iJ I SO I ,L EVAL UTATOR : T))A,e-�e � C��e ETIIS PLAN,®1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE BOARD OF HEALTH REGULATIONS. WITNESS : �07 - 'Uf REFERENCE: d I� DATE: �, l T r7.. ,', C7" 2) THE 114STALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLAT ION RATE: L �1 ��ta�1 b1, . SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO Cf �.5 1 SOIts INSTALLATION. tiT ,� TH- I (y; �� TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION Ci�� V 5 ��`r ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE DETERMINATION. Z x� 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS J �� f SPECIFIED O7'EIER�UISL) (0At / 1 LOCATION MAP (rJ .T.S ) ) �7.S 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A {, GARBAGE DISPOSAL. - M 6 DI um 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) C S' MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. 2-Sy 1, 9), A16 X A 0 AL w1Lq-19 E&q-&56-Q 97 01' 00.0 SEPTIC SYSTEM DESIGN ��� �lU ._w L�p,�_ w ��+_ /4�q' FLOW ESTIMATE l01 /116 1/��°1'�� ��M ����/ Dr2_��WN �F- ��9'/zm BEDROOMS S AT Ila GAL/DAY/BEDROOM 30 GAL/DAY SEPTIC TANK 330 GAL./DAY x 2 DAYS 6�0 GAL USE 4gDc-> GALLON SEPT I C TANK �/S%i�V�- i�P��4� �i� i S°�l' Sl?p 7i4nlaC _ ~. l p >=, I LED, j�}-AA A-q CIO� &� SOIL ABSORPTION SYSTEM �� ►Zr4.� To N . u iw) A t-S I D 05 2 `c- l3' x 2 b 91 _ '� __ ` _ __ — -- — `` � S1DE AREA: 25 � �-�13��-� X2- k" O, 7V = l�2 . Ltgr BOTTOM ARE 2 Z yb.�D g y— 6 � — -- SEPTIC SYSTEM SECTION N T 70 I I3,Sl fo GvG7sG)Pc! the J a' 9� 7.EL .:.. ,sue s .� G t 3 / / �,OCX? GAL �2.3d a-icsl< �30� -1-� -t_ SEPT I C TANK �r r�°l✓te-5 S � 5 �, t 1 v Y zs 0 v f x�srrti f r_ i2 [)ou t e N� SITE AND SEWAGE PLAN � � -��oF�SS . LOCATION : 42_ Nfl%'lJ EYt No. 1140 � � PREPARED FOR : t r"- Gi 77 � Ia ALE � ARKEN M. MEYER,IVIEYER I .S. r 43 VINE STREET DATE : 946 -Q3 DuXSURY, MA 02332 H67 t�1 9b-tl th NG"611 �� DATE HEALTH AGENT (781) 535-0293 a ,