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Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4,M
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
- information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown 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 A. General Information
forms on the31
computer,use 1. Inspector: C 51 U1
only the tab key
to move your Scott Campbell
cursor-do not Name of Inspector .
use the return
key. Cardinal Construction
Company Name
32 Ridgetop rd.
Company Address
Cotuit Ma 02635
'E"01 City/Town State Zip Code
508420-1295 S1388
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 F her Evaluation by the Local Approving Authority
y4/16/2011
'Inspectors Signatlr Date
w 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 ,
or greater, the inspector and the system owner shall submit the
has a design flow of 10,000 gpd
report to the appropriate regional office of the DEP. The original should:be sent to the-system owner
and.copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use"
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 Official Inspect*pn Form:Subsurface Sewage Disposal System•Page 1 of 17
�_,
rr
3'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
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:
Z 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:
Replaced disrtibution box
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair,as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 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 Voluntary Assessments
„M
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is Barnstable Ma 02630 4/16/2011
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Y rY
M 209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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 years usage(gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: 2011
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 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
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
11/5/1983 compliance date
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 10"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:
Sludge depth:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 209 old jail In.
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. CityTTown 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
4'Y
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? tape measure, sludge stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank should be pumped every two to three years.Tank in proper working order at time of
inspection.No signs of leakage at time of inspection.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 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
;M 209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is Barnstable Ma 02630 4/16/2011
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
Installed new d-box. No evidence of solids carryover prior to replaceing d-box. Equal distribution to
both pits new box was inspected by Barnstable B.O.H. Speed levelers in new box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°wM 209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
EJ 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.):
Course gravel, no signs of hydraulic failure, no ponding, dry soil, normal vegetation. (grass)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11110 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
N c 209 old J
GSM ail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of 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.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
tt
J
" l
k
t5ins-11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12+ feet
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:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Excavation at time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
209 old jail In
Property Address
Douglas Campbell
Owner Owner's Name
information is required for Barnstable Ma 02630 4/16/2011
every page. Citylrown . State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
No. a V 6 l —v �7 Feei—
E COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
_ �
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Rpplifation for Disposal *pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.ZO f 01D_74,L AA.,). Owner's Name,Address, d Tel.No.
Assessor's Map/Parcel a k" I Q �&� eq��Z'/el
Installer's,Nap,� Ad�e ,a Tel.No. Designer's Name,Address,and Tel.No.
71f � �&C- VZ o rZ 9
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(min.required) �j(7 gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1000 (5�4110A) Type of S.A.S. Z 000 at/b v g
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) e-e-
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 En ironmenta ode and not to place the system in operation until a Certificate of
Compliance has been issued by this Board f e th. f
Signed Date
Application Approved by / Y ( Date 1/
Application Disapproved by Date
for the following reasons
Permit No. 0-0 ' V C Date Issued
��
,
No. I ( r `� 1 Fee 1 6b.
E COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
RppYication for Misposai Opstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. A A,1. Owner's Name ,Address d Tel.No.
Assessor's Map/Parcel g -7 C)rJ �L� G/
Installer's;Nacp,AAddr�s,go Tel.No. Designer's Name,Address,and Tel.No.
�{ff CC
Type of Building: �7
Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
2 ; .
Design Flow(min.required) gpd Design flow provided gpd
Plan,' Date Number of sheets Revision Date
Title
Size of Septic Tank 9411Oti Type of S.A.S. _ I 100o y a/Ib v q,r #
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4:�a_ /
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 En ironmenta ode and not to place the system in operation until a Certificate of
Compliance has been issued by this Board f e th.
nSiiggned�^ Date
ApplicationApprovedby / ►' ` I Y ` ( (� Date / b�
Application Disapproved by Date
for the following reasons
Permit No. -o I Date Issued
--- ----------------------
(G THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,-that the On-site Sewage Disposal system Constructed( ) Repaired C d( )
Abandoned( )by g
at 0 -.,a Q � has been co str ted in a cordAnce
with the provisions of TiA 5 and the for Disposal System Construction Permit No. dated
Installer Designer
#bedrooms Approved design flo \ f gpd
The issuance of this e i�Vr
t be construed as a guarantee that the system will nction s design . r
Date � Inspector �! J
_ ------------------ - ----=--
---------------
No. 2 y l! 6 }� Fee 6D
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Re air(✓� Upgrade( ) Abandon( )
System located at a 0 o/d � �y)
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must a ompleted within three years of the date of this permit. / y
Date �� � ' Approved by .,/"C�r�-LC -�
s
L O CATION SEWAGE PERMIT NO.
/-or¢�z oi-,o 7411- t-ti
VILLAGE
I N S T A LLER'S NAME i ADDRESS
OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED2
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07/31/2002 14:03 15087755245 ANCHOR HV PAGE 01
LOCATION $ [ WAGE PERMIT fool
�o rjet 0/-d
f VILLAGE
INStILLfR'S NAME i ADDRESS
!— on OWNER
L I AZ 4,0-0e 11z tf M
OA T E P ERMiT ISS EY�
0 A T E COMPLIANCE ISSUED !/ I-f
1 .
Fizs.............. .............
I { THE COMMONWEALTH OF MASSACHUSETTS
q fi BOARD OF HEALTH ;
10.414....................0 F..7t Mz, }4 Q.�.�---................---.....---....----
94 A liratiou for Disposal Works Tomitrurfiaaaa ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
p y
. .. ................................................................. '"®-t�-�..--® ..�LT�.�.r....l� .. ......
uy
Loc on-Address or Lot No.
•- ----------------------------
••--
Owner Address
Installer Address
Type of B > ding Size Lot- ..__......Sq. feet
U Dwelling—No. of Bedrooms........ . --___Expansion Attic ( ) Garbage Grinder 0)
`4 Other—T e of Building No. of persons............................ Showers ) — Cafeteria"(
Q' Other fixtures ----------------•--------------- -
W Design Flow.................�-5_--..................gallons per person per day. Total daily flow............S��--.-................_..._gallons.
WSeptic Tank—Liquid capacity./V .gallons Length------g'....... Width---- --------- Diameter................ Depth...''.....__.
x Disposal Trench—No_____________________
Total
Length leaching q
Seepage Pit No-_-_--/--.---____-- Diameter.... ® Depbelowinlet.....6...._..__Totalleaching area.,;2�.f..sq. ft.
Z Other Distribution box ( ) Dying tank�(� )��� '- Date.___ ��.. ...................
'—' Percolation Test Results Performed b ._.�---- �! $ . -
aTest Pit No. 1..................mmutes per inch Depth of Test Pit Depth to ground water./1/__. .....
f14 Test Pit No. 2................minutes per inch Depth of Test Pit................._.. Depth to ground water---____------__---.__-_.
Ri
O Description of Soil..............R..'�.0f ........5;�?A D.........f evo 4.1 ----�G ! ,Tl ..................................
V ------------ ••-•-- -d���•/ ,1? ,f� ---.......--•--------•----------------------•----•---•---•--•------------------------.............---•-•-----------------
- ------
W --------------------------------------------------------------------- - -------------------------------------------------------------------------------•-------------------------•-----.._.........
U Nature of Rep 'rs or Alterations—A swe hen ap lica le_.____.........................................................................................
� � Os�
- .. � ----------- - -------------------------------------------------------------•------•--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee by the b.Qard of health.
Signed----- --- --••----------•- - S?`® •-----
Da
Application Approved By.....- f � � + 2'° i .......
ate
Application Disapproved for the following reasons-.................................................... ...........................................................
.................•----....-•---------.....---•--....------------------------------..........--•---------.._......_..._....--------•--------------•------------------------------------------------------.
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
.................... ...............OF......z.�1:21 /}p-l:.s........................
.................
Appliratilan for Ui,4pns al Works Tonotrur#inn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal }
System at: M
aT....... aL�.{�---eft,_L.--.L. �U......-----
Location-Address or Lot No.
............ ......................................._............... .._......._... ....... .............
Owner ..��++��''^^ ......•....... ............Address
a 1d........ Pl > �. ............ ............. ............----
o
Installer Address .�
UType of Building Size Lot_. -0.. __..Sq. feet
Dwelling—No. of Bedrooms........3...............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............_............... Showers ( ) — Cafeteria ( )
Q'' Other fixtures .------•------------------------------------------ --
w Design Flow................5 5.. ..................gallons per person per day. Total daily flow.............IS ....................gallons.
WSeptic Tank—Liquid capacity: .gallons Length............. Width..:-.ate___--___ Diameter________________ Depth....:4........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.
....../___._.__-__--- Diameter...../��_fj__. Depth below inlet................ Total leaching area._./....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by,.:_..� U! -1................................... Date.....13/Z/gam--_-------_
,.a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water../ 15V ..._.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---•-------------------------------------------------------•---•--•--------------------------.------........................................................
0 Description of Soil.............. .......... tV�o.......... !Jr- ------.CGad.V----1 4-------------------------------------
w
-------------------------
-----------------------------------------------------------------------
UNature of Rep ' s or Alterations—A we hen a lica le...___..........................................................................................
. _.
.Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT L is 5 of,the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee by the rd o4 h th.
Signed----- ...... - _- = 0. 1._.._.._
Da
Application Approved By...... e A. ..... ._. ---- � ---
ate --
Application Disapproved for the following reasons-------------------------------------------------------------------------------•-----------------------•-•--•---
----------------.....................................------------------------------------------------------------------------------------------------------------------------------------------------
Date
Permit No--------------------- Issued_------.........----
_ ...--•---- ---------------------- ...................................
Date
•,r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................OF..............................................................I....................
Trrtifiratr laf Toutphattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by--------------------•----•-•------------------•-------- ----------------------------------In----------------------------•--•-•-------••-----------------------------------------------------------
at,.... Z. ..................4.... . ......
has been installed in accordance with thegKovisions of TIT�� ..
5 of�Tjhe tate Sanitary Code as described in the
application for Disposal Works Construction Permit No.___....._..�.. ____ ..... dated_............
.................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED A A GUARANTEE THAT THE
SYSTEM WILLLONCTION SATISFACTORY. f_
DATE.... .°cS.....� ---------------•----•----......--------------------•--- Inspector-- ......... ---------------------------......----........--•-•-------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:........................OF.....................................................................................
No....-----------q.--� FEE....._. .........
Ropo sal Works T-141notrurtilan rrutit
Permission�is_>reby granted.............................•--......----••-------------•--------•---------.......-----•------------•........--- ..........-----.........
to Construct r epair ( ) an Ind'vidu vc�age Dispos System
at No............... Z .... --- .........
...t.............
-------•--------------------------------------------------------
Street
as shown on the application for Disposal Works Construction Pe 't No..................... Dat�-----------------------------------------
...........................................
-----.....-•------•........................
Boof Health
,�y
DATE v ;/Jo.............
FORM 1255 H088S & WARREN. INC., PUBLISHERS
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TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
NAME L Mf I y® 1c le D-5
ADDRESS OL10 7141L- zk/ VILLAGE
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
0 0 6,91, 4
FA s T S/D E of 6 v1G0/Ad- a-o D 0 6:41
EAsr 51ae D/-- 0Z000 6450Gjn.0 Iy2 STEEL
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: I. T JZ 2. -I-G 1 . 3. -1_61 4.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED:
PASSED DID NOT PASS
NA T LQCATI pN
Vetori o r 5E:_ ,,,7 ncg„ PIA Barnstabl Rd,,
901,0K ,.
,11204 V"6/6 fi
rATF; PAT:?
°7 Apn.zl, 3 A� f't. is 1 ,
MAR 11 ip
MAR
T A SENDER:Complete items 1,2,3,and'4► 1
Add your address in the"RETURN TO"space
on reverse. ( 1
(CONSULT POSTMASTER FOR FEES)
i.The following service is requested(check one).
El Show to whom and date delivered 'I...`..;.. ..i —0
'
x9kShow to whom,date,and address'ofE delifvrery.. —¢
2.❑ RESTRICTED DELIVERY F, C 1' 4 —0
(The restricted delivery fee is charged in addition to y
the return receipt fee.) f 1, f 4 }
TOTAL S
3 ARTICLE ADDRESSED TO:
Mr. Jack Vetorino
Vetorino Bros-Inc.
z Old Jail Lane,BARNSTABLE,MA.
30
4. TYPE OF SERVICE: ARTICLE NUMBER
m ❑REGISTERED ❑INSURED
xXEICERTIFIED ❑COD P478 764 729
❑EXPRESS MAIL
p (Ahvap obtaIn signature of addressee or agent)
1 have received the article described a
mSIGNATURE ❑ Addressee Authorized agent
r
S. Al OF DELI RY
m
v
CS.ADDRESSEE ZDDRES9(Only of requested
83.
=� 7.UNABLE TO DELIVER BECAUSE: 7a.E
G INIT.
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UNITED.STATES POSTALSERVICE
OFFICIAL BUSINESS
Ej-1 a PENALTY FOR PRIVATSENDER INSTRUCTIONS �?�' >~JC Ly OFPOSTAGOID PA Nr name,address,andaP CodeIn the spacebelow. t:ltteehtotrontofvftle�epermit% I �3themiseefAitobadrae ndorse artldewfetum Necelpt Requested
djacent to number.
RETURN
TO
BOARD OF HEALTH — TOWN OF BARNSTABLE
i
(Name of Sender)
I
P. 0. Box 534 S'
(Street or P.O. Box)
HYANNIS MA 02601 0534
(City, State, and ZIP Code)
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1
P - 476 .. 764 . 729
RECEIP°{i-FOR CERTIFIED MAIL
NO INSURANCE COVERAGE PROVIDED—
NOT FOR INTERNATIONAL MAIL
(See Reverse)
Sent to
Mr. Jack Vetorino
Street and No.
P.O.,State and ZIP Code
Postage $
.Certified Fee,
Special Delivery Fee
Restricted Delivery Fee
Return Receipt Showing
to whom and Date Delivered
Return Receipt Showing to whom,
N Date,and Address of Delivery
ao
TOTAL Postage and Fees $1,55
d
k, Postmark or Date
o 00 i
mailed 8/26/83
0
STICK POSTAGE`STKMPSi AARTICLETTCOVER'TIRST"CLASS-POSTAGE,
CEWI1'f1Ed'�A11:fEF,-AAD�HAR�ES F16R AAY�ELECTE0�9PT[IyKAZS�RVf�$;`s�ha� '
1.IfyouNacutjis receipt postmarked stick the gummed'61&snthe left portion oftheaddrasss1de
ofttietf lea i gAireceipiattac had aridpresentthearticreataposfofficeservicewi�doviioi
f•.._f'hand it to your rural carrier.(no extra charge)
— '2.If you do not want this receipt postmarked,s'ftclt Me gtmtmgd stub on the felt portion of fhs.
i address-stde of the article,date,detach and retain The receipt;arid-mA-the arttcte,
3.rf you w mu a return receipt;write the certified-man number and your name and address on a
rcaurn recei`pt card,'Torm 3811,and attach iftoaihefront:ofthd-art cfebVmeans of t ie gummed`endf9
^� if space.pp"s.Otherwise;affix to back of arttcte.Ertdbrse from of arstcte REf[1LfN RECEIPT
REQUESTED adjacent to the number. ;
4.Ifyou want delivery restricted to the addressee,or town authorized agent at the addressee
endorse RESTRICTEM MFVERY on the from of the articte.
&Ewter fees for the services regi ested'in We appropriate;P9C''esron the frdrtt oT 1L4f9 recefpt ff
return receipt is requested,check the applicable blocks in[r m L of form 38f 1.
6.Save this receipt arldpresent it ifyou make inquiry.
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,` Mass® 02645
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Barnstable
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TANK TO TEST CAPACITY F,oT
Station Chen
O rJ By most occur eq a Ov Tank Manufacturer's Chan
G/ Nominal Capacity Capacity-an .adaDle
m o .rlwa G.nen G.uoa •.J Company Enir ee g Dau
a. r ao n Is tbae doubt as to True Capacity 7 F ' I Charts supplied with TSTT
eYn....G.... Sea Section"DETERMINING TANK CAPACITY' - Otha
FILL-UP FOR TEST Stick Readings Total Gallons
to K In. Gallons ea Reading
Stick Water Bottom
before Fill-up
to H.in. Gdlons
Fill up.STICK BEFORE AND AFTER EACH COMPARTMENT DROP OR EACH METERED DELIVERY QUANTITY
Tank Dierneter / / Product in full tank(up to fill pipe) 0
SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK VAPOR RECOVERY SYSTEM
Sea manual sections applicable.Check below and—of procedure in log(28). J Stage I
Water in tank High water table in tank excavetlon Line(s)being tested With LVLLT Stage a
TEMPERATUREIVOLUME FACTOR(a)TO TEST THIS TANK 1
(617)432s216 Is Today Warmer?C Colder?'C F Product in Tank_•F FiO-up Proeuct on Truck_•F EXpeCled Change( •or-1
Thanna4Senscr reading char tdrwtetlon Q s�, .� 44 "F
Ncereal
D'gits per'F In rargp of expected chan"
JIM'S PUMP&TANK SERVICE'
FEATURING KENT-MOORE TESTING EQUIP. T� a
F X A b J U 5J D 0 V 9aepn,
10 I quantity M coefficient of expensicn flat rofums change in this taMt
fu tank(16 a 17) involved product por'F
p.0.BOX 224
JIM CHASE HARWICH.MA 02645 a t;/, ` ThisIs
cina yoti ms rlgo per•F(24) T Dlgha per-F in teat = Volume chaFqq per digit. test
Range(23) Compute to d decimal places facmr(a)
NYDROS7Ai1C NET VOLUME
FOLUIS 1111-MM:KR m TDOU1TUaE CG4XSQI04 ACCUMULATED
LOG OF TEST PROCEDURES PRESSURE IECggg Ip�1 CJL BSE EACTOt W CHANGES CHA►Y.E
CONTROL EACH READING
Stmdpio.Lined T.up.laiara u ty t,.a R 1
WE Record details of setting up sad,s a IecdYs Gat. TV.r
hod.d C.epinniee Adja ..at t y t--t
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and running test(Use full w volume uini,s
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TIM length of line it needed.) of .kid B.lon Aar I Preeaa R.wq I RI C'.tr.=rae- Comraaim 1_)
17r tr.l I R.ed'os R.Itmrd Reading F—dat R—ad 1'1 I .31M-.37E7) iriM vmW
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TANK TO TEST CAPACITY Prom
/ tala�e, _ sn char matt eccunb •V d — Tana Manolactu,er'a Chan
NDmmal caacin' O V
�'T`. io.n oow.an c.uons ce Dacny cnan wadable ca [
n /l n— Company Engmeermg Data
Is 1r,..doubt e[to Trua capacity r Chess supoiied with TSTT
7 a,. and Guaa Sao Secnon"DETERMINING TANK CAPACITY' ` Dine,
FILL-UP FOR TEST Stick Readings Total G.Ilons
to%in. Gallons as.Reeding
Stick Water Bottom „�_� —�•
before Fill-up Inventory �DD
to'A in. Gallon&
Fill up.STICK BEFORE AND AFTER EACH COMPARTMENT DROP OR EACH METERED DELIVERY QUANTITY
l
Tank Diemetsr G Product In Pull tank(up to fill pipe) Ov
SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK VAPOR RECOVERY SYSTEM
See manual sections applicable.Chock below and re-1 W—dure in log(26). Stage I
C Water in tank High water table in tank excavation Une(a)bang leafed with LVLLT step a
f
TEMPERATURE/VOLUME FACTOR(a(TO TEST THIS TANK
(617)432<216 Is Today Wanner?G Colder?, F Product in Tank_•F Fill-up Product on Truck_•F Expected Charge(-of-)
Thermal-Sensor reading attar cisfarhotion "g 3C6 4 'F
a�I )aago,y PW m
JIM'S PUMP&TANK SERVICE} Digits par-FIn range of expectedwagia _C , .
FEATURING KENT-MOORE TESTING EQUIP.
x - 00d4 0 a V y V gallons
tattif querttity In cces"id—t of expansion for —lurns change in th!a tank
tug tank(16 or 17) inyolyed product per•F
P.O.80K 224H a -
)IM CHASE HARWIC ,MA 02645
volume charge per•F(24) Dlgtta per•F in test Volume change,per digtL test
- - ---- Rego(23) Ccmpite to 4 decimal places. factor(a)
XYDESSURE 16W1[WAS➢KNE1111 m TEYPERQI[RE[o&F06g1N NET VOLUME kCCUMUUTEU
l06 OF TEST PROCEDURES PRESSURE RECORD To.")UL USE FkCf6N(y CHANGES CHkN6E
cDNTRDL EACH RFAD!N6
Taareantes
Snadviaa La.tl I I u NO law rs.s
LUTE Record details of setting up lei+ Pn dad is
r19e'd M—g. C—Potarias Adiauwcat Ter Ea.D.!emu
aa1Gq Cv.duat. ReWeM(-) TE.rwd Hi�.0. I (0•ta)- hba.:me um,s
and running test(Use full as aepiim6s L.vl t. Suns Later- E.Daaso. u Lit,Law cmi,"
IDnpth of line it needed.) d .kids a,l— khsr l rrw.n R..di. E[oeromn 1�)a
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Old Jail 'Lane, Barnstable
Vetorino Bros, Inc.V
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ARCHITECTS
BROWN LINDQUIST FENUCCIO&RABER ARCHITECTS, INC.
203 WILLOW STREET SUITE A YARMOUTH PORT,MA.02675
TEL, (508)362-8382 FAX. (508)362-2828 - -
BUILDING CONTRACTOR
AP KIMBALL CONSTRUCTION
84 HOMBERS DOCK ROAD YARMOUTH PORT,MA.02675
TEL. (508)208-9854
PROGRESS SET
04. 14. 2014
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oo" ELEV.
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tz' PERC RATE MIN/IN.
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spa ` Y bE"i '`o REQ'D SEPTIC TANK SIZE t vpo \ /
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3 wt.-DCes SIDE WALL Cf x (2.5 ) = 3-t-I.c�o G/D.
BOTTOM '
to€" gckg TOTAL Zo)-t = 4z_-t.2-) G.tb,
4- USE: n►la' LEACHING IT \ p'• 1
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WATER ENCOUNTERED
NOTES (UNLESS:OTHERWISE NOTED) OF cD
_
1, DATUM (MSL)'TAKEN FROM ...._____,___,__QUADRANGLE MAP
2. MUNICIPAL WATER___ IS NOT AVAILABLE
3. PIPE PITCH: '/4"PER FOOT aAMf�i
4. DESIGN LOADING FOR ALLPRE-CAST UNITS: AASHO- �- 4 -44 H- -
5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1),FT. v EIOW,.4AN C/) DISTANCE AS CERTIFIED r —
6. PIPE JOINTS SHALL BE MADE WATER TIGHT #21038 '
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS..
STATE ENVIRONMENTAL CODE TITLE 5j� r+�TEgS^C,0. 1 HEREBY CERTIFY THAT THE BUILDING SITE PLAN
SHOWN ON THIS PLAN IS LOCATED ON THE
f Sa, t�ti GROUND AS SHOWN HEREON &THAT IT LOCUS:
--- CONFORM TO THE ZONING BY LAWS OF THE
--------------- TOWN OF
REG.PROFESSIONAL ENGINEER WHEN CONSTRUCTED. DATE C h. I`-
I � REF:
downCape efilil @@r*19 PREPARED FOR:
tsSCs b+-'tca DT.SIGwa 1�6ao.1�G �uow�JG w�c�ra_ CIVIL ENGINEERS
L e.Gt#.�JcT+�L1LL?. ------------
LAND SURVEYORS '
BOARD OF HEALTH SURVEYOR LAND.
CONTOURS (EXISTING) ------------- � REG.
(PROPOSED)-0-0-0-0- APPROVED DATE �"a'� ST� MA Yarmouth&Orleans,MA SCALE DATE