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HomeMy WebLinkAbout0050 AUDUBON CIRCLE - Health 50 Audubon .Circle Centerville P 191 181 No. 4210 1/3 ORA Lr- 10-)(3)ImdzQD(B)K a ESSELTE 10% (a 0 0 0 0 IY1�4Y�w4aauc�i Commonwealth of Massachusetts Title 5 official Inspection Form r�.a i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments j f t. 50 Audubon Circle, Centerville, MA _ IN." Property Address $ c/o Francine Melanson 15 Ardmore Road Owner owner's Name "t information is Worcester MA 01609 8/28/2018 -M required for every page City/town State Zip Code Date of Inspection taT 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 A. Inspector information Sl*- 133 03 filling out forms on the computer, use only the tab Joseph M Martins key to move your Name of Inspector cursor-do not Accu Specheck use the return Company Name key. 17 Northside Drive rab Company Address South Dennis MA 02660 City/Town State Zip Code 508-385-5891 S1 147 Telephone(dumber License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8/30/2018 spector's Signat 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc-rev.7126/2018 Tile 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 Of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Fors Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester _MA 01609 8/2812018 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: RECOMMEND REMOVE GREENHOUSE AND ITS FOUNDATION NEXT TO SEPTIC TANK. SEE NOTE PG 14. 2) System Conditionally Passes: One or more system components as described in the" ondi nal Pass"section need to be replaced or repaired.The system, upon completio f th placement or repair, as approved by the Board of Health, will pass. Check the box for"yes","no"or"not d to ine " Y ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 y ar or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiitratio exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replac ith a complying septic tank as approved by the Board of Health.. *A metal septic tank will pass' spection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that tank is less than 20 years old is available. Y [ N ND(Explain'below): t5insp.doc-rev.7126=18 Title 5 official Inspection form:Subsurface sewage nisposal System•Page 2 of 18 f Commonwealth of Massachusetts -_- Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every -- page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 disttl�iution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ ND(Explain below): ❑ obstruction is removed ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replace ❑ Y ❑ N ❑ NID(Explain below): ❑ The system required mping more than 4 times a year due to broken or obstructed pipe(s).The system milli pass ins elation if(with approval of the Board of Health): broken e(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obs ction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: 15insp.doc•rev.7/2612 0 1 8 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA_ 01609 8/28/2018 required for every State Zip Code Date of Inspection page. City/Town C. Inspection Summary (coat.) ❑ 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 b. 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(SA and the SAS is within 100 feet of a surface water supply or tributary to a surface wat supply. The system has a septic tank and SAS and the SAS is in a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SA s within 50 feet of a private water supply well. Fj The system has a septic tank and SAS and the AS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: x*This system passes if the well water anal y is, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the res nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o er ilure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc-rev.7J2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 ' Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owners Name information is Worcester MA 01609 8/282018 required for every page CityfTown State Zip Code Date of inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No ❑ 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'/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well- ❑ N 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 2000 gpd- 10,000 gpd. ❑ ED 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. 5) Large Systems: To be considered a large system the system m 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 ch of the following, in addition to the questions in Section CA. Yes No the system is with 400 feet of a surface drinking water supply ❑ ❑ the syste . within 200 feet of a tributary to a surface drinking water supply El ❑ the tem is located in a nitrogen sensitive area(Interim Wellhead Protection a—IWPA)or a mapped Zone 11 of a public water supply well l5insp.doc-rev.712 6120 1 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes' to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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 volmes 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 bF k o t? jAIS ® ❑ Were all.system components, ding 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)] t5insp.doc-rev.7/26/2018 Tifle 5 Official Inspedion Form:Subsurface Sewage Disposai system•Page 6 of 18 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 50 Audubon Circle,Centerville, MA Property Address clo Francine Melanson 15 Ardmore Road Owner Owners Name information is Worcester MA 01609 8128/2018 required for every page. City/Town State Zip Code Date of inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: 1000 GALLON SEPTIC TANK, NO DISTRIBUTION BOX,AND A 6'X6' PIT W>=2' STONE. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes 1Z No .If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? 0 Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): 36 Detail: 2016: 11,000 G G 2017: 16,000 G Sump pump? ❑ Yes Z No PRESENT Last date of occupancy: Date 15insp.doc-rev.712612018 Idle 5 Official Inspection Form:Subsurface sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every — State Zip Code Date of Inspectionpage. CityfTown D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment.- Design flow(based on 310 CMR 15.203): Gallons per (gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title system? ❑ Yes ❑ No Water meter readings,if available: _. Last date of occupancy/use: Date Other(describe below): I 3. Pumping Records: Source of information: PUMPED IN 2016 PER BWWTP Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7@612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Dorm a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h 50 Audubon Circle, Centerville, MA -' Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: z Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool El 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): NO DBOX Approximate age of all components, date installed (if known)and source of information: HOUSE BUILT IN 1974. 44 YEARS. Were sewage odors detected when arriving at the site? ❑ Yes ® No I 5. Building Sewer(locate on site plan): 2 Depth below grader feet Material of construction: EJ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10 feet Comments(on condition of joints, venting,evidence of leakage, etc.): FLUSH TESTED NO LEAKS. 15insp.doc•rev.7126=18 Title s ofridal Inspection Form:Subsurface Sewage Disposal System•Page of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ��{ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Flame information is Worcester MA 01609 8/28/2018 required for every page. CitylTown State Zip Code Date of inspection D. System Information (coat.) 6. Septic Tank(locate on site plan): Depth below fade: 0.5 p g 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) 0 Yes ❑ No APP 8.5 X6X5 1000 G Dimensions: Sludge depth: — 9 INCHES - — Distance from top of sludge to bottom of outlet tee or baffle 25 INCHES 0 INCHES Scum th ickness Distance from top of scum to top of outlet tee or baffle 6 INCHES Distance from bottom of scum to bottom of outlet tee or baffle 14 INCHES How were dimensions determined? CORETAKER Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): HAS CONCRETE INLET TEE. HAS PVC OUTLET TEE. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE. RECOMMEND REMOVE GREEN HOUSE FOUNDATION NEXT TO SEPTIC TANK. $insp.doc•rev.7rM2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal system•Page 1 a of 18 I Commonwealth of Massachusetts w Title 5 official Inspection Form 11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments (� 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: /feet P 9 Material of construction: El concrete ❑ metal ❑fiberglass ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee affle Distance from bottom of scum to bottom outlet tee or baffle -� Date of last pumping: Date Comments (on pumping recomme lotions, inlet and outlet tee or baffle condition, structural,integrity, liquid levels as related to outlet i ert,evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of ins tion) (locate on site plan): Depth below grade: NIA Material of construction: ❑ concrete ❑metal ❑fi rglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Moat Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts -, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville,MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's(dame information is required for every Worcester MA 01609 8/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8.. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ /E01 Alarm level: Alarm in working o ❑ No Date of last pumping: Date / Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping cont t(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must opened)(locate on site plan): Depth of liquid level above ou t invert NO DBOX Comments (note if box is 1 el and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into out of box, etc.): -Z t5inw.doc-rev.7Y1 O18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every page. Cityrrown State Zip Code Date of Inspecti D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: /and ❑ Now Alarms in working order: ❑ No* Comments(note condition of pump chamber, conditis, etc.): *If pumps or alarms are not in w king order, system is a conditional pass. 11. Soil Absorption System(S ) (locate on site plan, excavation not required): If SAS not located,expi why: Type: ® leaching pits number: 1 sxs W>=2'STONE ❑ leaching chambers number: ❑ leaching galleries number: EJ Teaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: El innovative/alternative system Type/name of technology: t5insp.doc-rev.7l2&2010 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle,Centerville,MA `�. Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every — page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(coat.) . Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): LIQUID LEVEL IS 1'.VARIABLE MODERATE STAIN LINE. STONE IS CLEAN AT 2'ABOVE PIT BOTTOM W SOME VOIDS. SOME INDICATION ON INLET PIPE OF A HIGH LEVEL IN LEACH PIT -DOES NOT APPEAR RECENT. .THIN PIPE IN SYSTEM. PREVIOUS TITLE 5 REPORT IN 2007 INDICATES PIT 3/4 FULL. 12. Cesspools (cesspool must be pumped as part of.inspection) (loca o 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 i low ❑ Yes ❑ No Comments(note condi n of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5nsp.doc•rev.7/26/2018 Title 5 Official Inspection Forrr Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts :- Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is required for every 1 1 Worcester MA 01609 8/288 page_ Citylrown State Zip Code DLUriof Inspection D. System Information (cont.) 13_ Privy(locate on site plan): Materials of construction_ Dimensions Depth of solids Comments (note condition of soil, si/hyaulicre, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2612018 Me 5 Official lnspe0on Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is Worcester MA 01609 8/28/2018 required for every _ page. CityfTown State Zip Code Date of Inspection D. System Information (coat:) 14. 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 t W A 6 � U DISTACES At- Z S•S' 61-31.s' . 3 O A3= y2•5 UP 13.#� t5insp.doc•rev.712612018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora it Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville,MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is required for every Worcester MA 01609 8/28/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 15_ Site Exam: Check Slope Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14.2 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: FILE,PREVIOUS TITLE 5 REPORT ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: FRIMPTER TABLE You must describe how you established the high ground water elevation: SEE ATTACHED TABLE PG 18. SAS SITE IS 50'ASL. BARNSTABLE GROUNDWATER CONTOUR 6/1992 AT 32'ASL. GRADE TO SAS BOTTOM IS 8.65', MAX RISE SDW252D FOR 6/1992 IS 3.8'. SEPARATION MATH: 50432+8,7+3.8)=5.6'. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5irsp.doc•rev.7/26/2018 Title 5 Official lnspec$on Form:Subsurface Sewage.Disposal System•Page 17 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Audubon Circle, Centerville, MA Property Address c/o Francine Melanson 15 Ardmore Road Owner Owner's Name information is required for every Worcester MA 01609 8/28/2018 page. City/Town State. Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A.inspector information:Complete all fields in this section. ® S. Certification: Signed&Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 1.5: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7I2W2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . 1 _ DEPARTMENT OF ENVIRONMENTAL PROTECTION '( 5 iOAP PARCE4 : 1 1 LOB TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 50 Audubon Circle S--;f Centerville �J � Owner's Name: Charles Melanson • . Owner's Address: Date of Inspection: C3 `' i rr t Name of Inspector:(please print) W i 11 i am E_ •Robinson Sr. Company Name: William E. Robinson Septic Service cr, Mailing Address: P O Box 1089 ' Centerville, MAO c.� .. Telephone Number: i5081 775-8776 rn� CERTIFICATION STATEMENT I certify that 1 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 15340 of Title 5(310 CMR 15.000). The system: 1/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Sigdature: l- ��C i.� p Date: 7^ -'O The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing authority. Notes and Comments "This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued)- Property Address: 50 Audubon Circle Centerville Owner. Charles Melanson Date of luspectioo: — (3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: L 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: B. Sys m Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. he system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer s,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, khibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A metal eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND expla O servation of sewage backup or break out or high static water level in the distribution box due to-broken or obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval f Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND exp ain: e system required pumping more than 4 thus a year due.to broken or obsWucted pipe(s).The system will pass ins ction if(with approval of the Board of Health): broken pipe(s)are replaced >. , obstruction is rtmloved ND explain: v Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 Audubon Circle Centerville Owner:-Charles Melanson Date of Inspection:. C. Furt er Evaluation is Required by the Board of Health: Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to rotect public health,safety or the environment. I. Syst in will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syste is not functioning in a manner which will protect public health,safety and the environment: sspool or privy is within 50 feet of a surface water _ C sspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fu rictioning in a manner that protects the public health,safety and environment: _ Thi system has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a surface ater supply or tributary to a surface water supply. — Th system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. _ T e system has a septic tank and SAS and the SAS is within 50 feet of a private water supply.well. e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a privat water supply well'• Method used to determine distance ••Th- system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacte is and volatile organic compounds indicates that the well is free from pollution from that facility and the p esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fail a criteria are triggered.A copy of the analysis must be attached to this form. 3. (her: Lz", Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address. 50 Audubon Circle Centerville Owner: Charles Melanson Date of Inspection: Off/ D. System Failure Criteria applicable to all systems: You mu4 indicate`yes"or"no'to each of the following for all inspections: Yes N _ 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 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 I 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 f^.et from a private eater supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed al a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and (lie 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 forma (YesMo)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 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 faci!ity with a design flow of 10,000 gpd to 15,000 9 Yo •must indicate either"yes"or"no"to each of the following: (Th following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped Zone I of a public water supply well If you ve answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"it Section D above the large system has failed.The u%mer or operator of arty large system considered a signific int 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. r' 4 i v Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Audubon Circle Centerville Owner: Charles Melanson Date of Inspection:_7-2qr-0 it Check if the following have been done.You must indicate`des"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health ere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? 2/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? L/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: Yes ri 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 Audubon Circle Centerville Owner: Charles Melanson Date of Inspection:�2—j a--a�-i FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):.,. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms):3 C C) Number of current residents:LA Does residence have a garbage/grinder(yes or no): Is laundry on a separate sewage system(yes or no):0 [if yes separate inspection required] Laundry system inspected(yes or no):-Ae Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 3 — 5 8 r 0 0 0 Sump pump(yes or no):. 2 — 106, 000 Last date of occupancy: — `1•0 � C'O IAIANDUSTRIAL Type of m C1171ishment: Design flow(based on 310 CMR 15.203): tpd Basis of de gn flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial aste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water met r readings,if available: Last date f occupancy/use: OTHER escribe): GENERAL INFORMATION Pumping Records Source of information: /41- Was system pumped as p6t of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYYOF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source [information: `� Ll Ar ca Were sewage odors detected when arriving at the site(yes or no): A�_G 6 Page 7 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Audubon Circle Centerville Owner: Charles Melanson Date of Inspection:_ .g e}—pd/ BUILDING EWER(locate on site plan) Depth bolo grade: Materials o construction:_cast iron _40 PVC_other(explain): Distance in private water supply well or suction line: Comment (on condition ofjoutts,venting,evidence of leakage,etc.): SEPTIC TANK: 1/(Iocate on site plan) Depth below grade: ) Material of construction:_✓concrete metal fiberglass_polyethylene —other(explain) If tank is metal list age: Is age confumed-by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:( Lk G oL Sludge depth: !y_G Distance from top of sludge to bottom of outlet tee or baffle: ;L�l Scum thickness:2,.S ,, Distance from top of scum to top of outlet tee or baffle: °7 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:_6L=w G e v L`sz s Comments(on pumping recommendations,inlet and outlet tee or battle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_1 gate on site plan) Depth below grade:_ Material of construction: concrete._metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top ors m.to top of outlet lee or baffle: Distance from bottom f scum to bottom.of outlet tee or baffle: Date of last pumping- Comments(on punt ing reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet' vert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Audubon Circle Centerville Owner: Charl ps Melansion Date of Inspection: 0 5_© e% TIGHT or HOLDING T kNK: (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. allons Design Flow: allons/day Alarm present(yes or ): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(conditio of alarm and float switches,etc.): DISTRIBUTION ✓IlOh. (rf present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: /onan) Pumps in working order(yeAlarms in working order(yComments(note condition r,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5.0 Audubon Circle Centerville Owner: Charles Melanson Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): t/(locate on site plan,excavation not required) If SAS not located explain why: Type leachin its number: g P .� leaching chambers,number: - leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): G ® 0 j A e .. L L die516 �s Yvl CESSPOOLS. (cesspool must be pumped as part of inspection)(locate on site plan) Number and con guration: Depth—top of liq id to inlet invert: Depth of solids la er. Depth of scum la r: Dimensions of ces pool: Materials of const uction: Indication of grou.idwater inflow(yes or no): Comments(note ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (1 cate on site plan) Materials of con truction: Dimensions: Depth of solids: Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Audubon Circle Centerville Owner: Charles Melanson Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 9 �n 10 Pagel 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Audubon Circle Centerville Owner. Charles Melanson Date.of Inspection: 7—,;LOi O �l SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: G ecked with local excavators,installers-(attach documentation) ,--Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 � Issued........................................................ if Z y ,- ., _ .... •4 THE COMMONWEALTH OF MASSACHUSETTS OARD HEA TH -u! lto F .. A11 rd i In -for'1i-44jlalitt1 earls C onstrurtivii Vrrmit f . Applicatf is hereby made for a Permit to Construct ( ) or Repair ( , ) an Individual Sewage Disposal ystem at , .. ........................�_Lle&dfl ..........��G� Location,' Address i or Lot No. a. # - _ - Owner - n •..� ;- Address Address Q Type of Bulldiiig i. ize Lot...,J� j�Q 'Sq. feet U , "�'_- Dwellings—No. of Bedrooms..__ - __._,.__.___ anslon Attic ( Gar age Giiler ( .. ' a .s� Other `Type of Buil'diny No: o" eIpQYS __:,--_-_ Sh wrs ( ) — Ceria ( ) I ; a Other fixtures ,_1.---------• --------- by ,:.. K -- ----•--•-- ••-----„___- WDesign. Flow:,______ :_'.�'"�..._.... __gallons per person e/Ay otal daily flow._..._.._...�.0 r w � g la long ;R. .W Septic Lurk -Liquid capacity/as! gallons Length..... .._._..`Width. Diameter.............____ Dehch .--.-_ ._. . r x Disposal Trench No __-__-. ------- Width,_ _-___-_- Total Length al leaching Irel.. sq. it. Seepage Pit No...... ___.......:.. Diameter ...:/Q12 . Depth beloj inle "' " Total lea hing-trey--_ ___ -------__sq. ft. z Other Distribution box (' ) Dosing tank ( ) d,(/• / 9f�Z /7s�• �. .. Percolation Test Results Performed by------- -- ---- -„---_,_'_____-___*_.•:-___-_............................ .._........____.._....._ Date---------------------------------------- Test Pit No. 1------- minutes per inch Depth of Test'Pit.........:.:..::'__ Depth to ground•water'?' -_-- -------- GXq Test Pit.No. 2---- •... m.inutes per inch Depth of Test Pit.------------------- Depth to ground 'water/_ , �j��� Q O Description of Soil +- I_ fs _1t-f+�------ --- --------------------- _ '�` � UNature of Repairs or Alterations er when applicable ------------- Agreement: ----------------------------- t' R _ a :y _4 The undersigned agreeso to tall'-=•the'a'Y descri viduar Sewage Disposal System in accordance with the provisions of Article XI of•thle Late Sanita ode—T signed further agrees not top lace;the system in q L r t _ ncV,as b�issued by thy, d;of he�ltb.: operatio until a Certificate of pha ... ---- !. D te ' ` Application Approved BY• !�; +:•(�/ ...... s :/.d', .. .. �✓ ' D to Application;Disapproved for tltie'f o wing reasons. ` ....._:_. :.;____ '.. ._:.._ _ ` t .............................. ................. •-•------ i Permit No................... ---- --•-- ----- Iss ed. Date • #.i . , st ' `THE CO NV1h ,I.ASSAC •TTS - ` BO D OHEAL'T, Ya. �.� ., 3,..:. • ; �Frim 4 D[Ilt 'tFIYiCP , ; THI IS:TO TIFY, That the I Idu 1 Sewa c 6is 1 System constructed h -?`Re aired, g. ( . =` 11t 1 lu.t `/6N • t F �_•_ .___' - t i ......................q ,r _. ._.._..I S has;heentmstalled in accordance with,t a isiol�Sjo4*tAf�e � o Tlie ta, Saniiary Code as'scLi n the application-•:for Disposal Works Const' cti n Permit No:.__ _ dated ._._ .`_. _::�_ __'.. __________ THE,ISSUANCE OF'";`HIS C TIF CATE SHALL�,NOT BE C : NS UED_AS A GUARAPITEE-THAT THE SYSTEM WILL FUNCTION SATIS AC RY. DATE_ .......................... e r ; = -•- --- ----- - -- c4tO --_...... S Insp 1 y.� '��• -ar t- ... ,yrr it - .. .,M� '�bK'., q t� "�6 F� " � .Y�. �!� .... I ,, q _ .. a�- "' ,y 'THE COMMONWEALTH.OI MA SAC ' `BOARD O HEALT N0......�................... r FEE.../ �t���r�ttl: ��rrk,� >an�trurti>aat �rr�tit _ Permission'. reby granted Q: ..... '4 to Constr ,or- Re' I ' ( ;•) In vidual S e Di osal S • .� at N'o. --1�---• - Street` ................ -•• ...................................... . as shown on the application for Dispo.'sal Works Construction Per . 0.... . ...... ated__:. t�__�'.__ Board ofYHealth /r rDATE.._..' ... -,�"' .... •-••--------------- -------- FORM 1255 HOBBS,& WARREN. INC.. PUBLISHERS .. ' i{` ' ... .... .. .. 1 � �, � �. _ rt�- . l �� � � , t �. 1 i _ ,���� . `,� . . �r N ,, k s� gy _ � � , .+�� s Jt o �. .. . . G°� � .' - ' - - � �o u C� . . �,oT ram» � ._ � . � . . t » M � : � M b-U t_L- E-R-5-Q-Q1.A-E- Dh►`CE_PE.R_N�1�T 1_SSUE_D-"=J®�-�.1.-�°� 7 a 7 .�:�. .. 3 r i _ I�4 � .. .... ..,. t ,.,'� .. ... , 6' �� - s a -. �� �e � 1�