HomeMy WebLinkAbout0011 BELDAN LANE - Health 11 Beldan Lane, Centerville
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UPC 12543
No. R n-coNSJ`��o-
HASTINGS, MN
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No. 7 -7 Fee ��
THE COMMONWEALTH OF MASSACHUSETTS : Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIpprication for �Dioogal *pgtemc Comaruction vermtt
Application for a Permit to Construct( ) Repair( ) Upgrade(✓j Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. I I Be)dan LClrvt ner's Name,Address,and Tel.No.
Ceniervi11t✓ MceT -PtEeCE
Assessor's Map/Parcel M 4 1$ ?c r(.e i 1—D a 1 11 -B e j d0 n Ln,Cep+er V t LLE
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
RobeR-T &I{boy- 13+a ExcQyn}ton rNc_ Down Cope En ineert n
14 = q3qAcilh5+
o +
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
Design Flow(min.required) .3 3 gpd Design flow provided gpd
Plan Date 2-2 3-0 7 Number of sheets I Revision Date
Title rl_te 1J s t+P. 10 a
Size of Septic Tank { DL-) Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sig Date I -D 7
Application Approved b 2v� �� Date L3�
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
D�7 _ Fee / V No. -`"
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
0100/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for �Mpoal *pgtem eon.5truction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade(V Abandon Complete System ❑Individual Components
Location Address or Lot No. I I BEICICIt 1 Lone Owner's Name,Address,and Tel.No.
Centerville - �4bCET 4-'- 102CE
Assessor's Map/Parcel AA Cl l� 19 '7 Cl Q e I 3 1 -U 0 1 11 1�)e 1 CVp n L 0 ,(e 1 C(V 1 t L 6 r,
Installer's Name,Address,and Tel.No. Designer's Name,Address and-Tel.No.
Bile E x(CNCIAI&F) TWA Dow, Cope
1`I T 3 � Se � l /) P6F
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
Design Flow(min.required) 3 3 0 gpd Design flow provided gpd
Plan Date 2-Z 3- U 7 Number of sheets I Revision Date
Title T I I e r-) S,4 e Iri s l
Size of Septic Tank U C1 Type of S.A.S.
Description of Soil
l
Nature of Repairs or.Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sigr}c � -Yi Date
Application Approved b. Date
Application Disapproved by: Date
for the following reasons
Permit No. � Date Issued
z�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
a Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ✓)
=t` Abandoned( )by �t)br s2 i r&I LF 1)V :Big
at l S d a n LCA n e, L 1-1-I P( v 1 I I r` has
^been
^constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. !7 dated l �.
_Installer C3b( - Designer I v.r 1 G p P f r1/1 t c ,PP r r�C
#bedrooms J .Approved design flow 3 3 L gpd
The issuance of this permit shall not be construed as a guarantee that the syste��rri�i will function designed.
Date 15 _2 Inspect
-----�—(—'j—�-----------------------
No. (�- r ---- Fee /Q� ---
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
lwi!5po5ar *pgtem Construction Permit
Permission is hereby granted
-;to�Construct ( ) Repair ( ) Upgrade (�- ) Abandon ( )
System located at ( ��P_1 l o c� L Ci D P I r I l f' t AA
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construct' 4 b completed within three years of the date�of this r t .
Date Approved bye.
FROM :down cape engineering inc FAX NO. :15083629880 Mar. 05 2007 01:54PM P2
Town of Barnstable
Regulatory Services
Q Thomas F. Geiler,Director
" = Public Healtb Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Fpx: SOS-790-6504
Office: 508-962-4644
Installer & Designer Certification Form
Date- Sewage Permit#
Assessor's MapTarcel
0 2Installer: ��� X CQ✓Q
Designer: �' e, �
Address: L �oc Address: �°��� f Z^'
�-V-
On was issued a permit to install a
(date) ,+_ Jseptic system at �� tej�,a L�1 �" Cep &-V'I((C based on a design drawn by
(address)
dated
(de W gner)
I certify, that the septic system referenced above was installed substantially according to
the design, iwhich may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than l 0' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified Ls-built by designer to follow_
<A
MOF
p ASS
1(R AI E. H
(Installer's Signature civil_
N
• 9/ NA
( esign 's Signa �(Af ix )es _ er's mp Here)
PLEASE RETURN TO BARNSTABLE P[IBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WI1,I, NOT BE ISSUED UNTII, BOTH THIS FORM AND A_ S-13LliL?' CARD ARE
RECEIVED BY T'HE BARNSTABLL, PiJBLIC HEALTH DIVISION. 'rH.ANK YOU.
Q:HeahWScptic/DesiFncr Certification Form 3-26-04,doc
TOWN OF BARNSTABLE
LOCATI6; I I BcJckotr1 Lark. SEWAGE# ,700'? - 71
VILLAGE 0cn1r r U J It- ASSESSOR'S MAP&PARCEL 199 31 — o0 I
INSTALLERS NAME&PHONE NO. Q e$ £XcavcLTsoN
SEPTIC TANK CAPACITY 1000 4,2,)
LEACHING FACILITY:(type)_Soo 9 (Z) (size) 13 x PS'x 1.
NO.OF BEDROOMS 3
OWNER -P,'c cL
PERMIT DATE: 3 - /- 0 17 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
Al Zs•s �.•
$)
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FEB...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .....oF.... A..c1 ✓1.. .....................................
ApplirFa#ion for Dispaii ai Works Tonitrnrtion ramit
Application is hereby made for a Permit to Construct k) or Repair ( ) an Individual Sewage Disposal
System at
CT f �����✓ .. ;rid e
................__....... ........................................... -•••-•--------•-•--•....•......._..------••------.........._--•---
-Locatio ddress or Lot No•
� . �� ti.... Apr Jl�.... � 11.� ,...... •......:. .............•_.... '.-....•.........--
�� � Address
14 1 Building Installer Address �
l'-Type of ilding Size Lot_ 5 ...Sq. feet
Dwelling—No. of Bedrooms_______........................._ _Expansion Attic ( ) Garbage Grinder (0)
p•, Other—Type of Buildin No. of persons............................ Showers (/) — Cafeteria ( )
a' Other fixtures ________________•_______________. .
W Design Flow........IZ•Q........................gallons per person per day. Total daily flow----------3_d3"._.Q_....................gallons.
WSeptic Tank—Liquid capacity/lf-9.Q_gallons Length................ Width................ Diameter_______:____.__- Depth................
x Disposal Trench—No-____________________ Width.................... Total Length_________ ... Total leaching area....................sq. ft.
Seepage Pit No-------/.......... Diameter... Depth below inlet____ ........ Total leaching area_.42_{_K ..sq. ft.
Z Other Distribution box K ) Dosing tanjc
'-' Percolation Test Results Performed b ...__ � � �"' !^��°AC^�'____________________ Date...3.___ __
Test Pit No. 1.....c?......minutes per inch Depth of Test Pit-----/•3_....... Depth to ground water.....__.............
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------
•___________.
x ••••-•••-• ....-••--•-•••-------------••• -
O Description of Soil_._C� /'��--�----� -- _r v,� ' - - BQ �--1� _�le����' ----------------
W
U Nature of Repairs or Alterations—Answer when applicable---------------------------------
.............................................--•-•----------------------------•----•......--•---------------------------------------------------------.... ............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the oarpf health.
Signed__a.4:;5 .... /'-1 E��2 ----•-------••---_-____ e1/0 ....
Date
Application Approved By_--. - .._ .�......
/ ' y Aw........
-----_..
Date
Application Disapproved for the following reasons____________________________________________________________________________________________________________•_...
--••-----...--•------•-------•--------------•----------------...-•-----•-------------.......--------•••---•---------------•-•-••••--••-------••-•-----------•-•-•••••--•-•---•-•------••-------...•••---
Date
l`
Permit No......................................................... Issued-..... _-•- •`�
Date
".....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. d�li! .± .......................................
ApplirFation for Disposal Works Tonutrnrtion Prrutit
Application is hereby made for a Permit to Construct , '') or Repair ( ) an Individual Sewage Disposal
System at:
......... ................. ......__......_... .. r�1 =... _.._.. .......__..._._.........._.....
Locatio - ddress r or Lot No •
J.- ,
4 7 �1 1L sf/L�✓tr i � t.._ 14' - f _ "� i,.. � �tlf- r 1.f \1..................
.....»_. ..-•----------•-•--
,.�� OwnerJV Address
.'t�; -•--------------------------------- ---------- ?IV 4 ....-•--•----•----- .......---._.......----•--•-------........----
Installer Address
U Type of Building ��yy Size Lot.4 . _...._..Sq. feet
Dwelling—No. of Bedrooms---------- .............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building 4 _ 6wrI _ No. of persons............................ Showers
� yP g ------•-•--'- - - - P (,� ) — Cafeteria ( )
Otherfixtures -•-------------------•-•---------•--------------------------------_-_---------•--......-_-------------...
W Design Flow........11L. ........................gallons per person per day. Total daily flow........., _ _ _......._._.......•..gallons.
WSeptic Tank—Liquid capacitylO.A()..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width. ............... Total Length........ .......... Total leaching area...................sq. ft.
Seepage Pit No..._.../........... Diameter../O........... Depth below inlet... ._........ Total leaching area. + K...sq. ft.
Z Other Distribution box,�< Dosing tank , = lr
'-' Percolation Test Results Performed by .... ti ----- Date_ ? ._
Wa ...---••-•. . ---...
Test Pit No. I.... .......minutes per inch Depth of Test Pit...../ ......_. Depth to ground water-____e12.............
(Z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a Description •--------•----
of Soil__C'> !'
------•••-
V ................................................
.........................•--------•- . r --•-------------------- ------..----•-•-------...-•-------------•--------......----•-----•-----
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--•----------------------------------------•--•------•----•------••----------------.....------------------......--------------------------....•-•••---------•_._.._....--•-•••........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TiTiE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar of health.
Signed--��1' .i . .t `, '%l ------------------•----- ......`...
Date
Application Approved By__4%_ ........................ t------------
Date
Application Disapproved for the following reasons:-------•••--•-------•-••---••-:•----•--•------•----.._..••••---------------•-••----•---_----•--------•--------
..------•-•--•--•................••----•-......---....--•-•-----.........----•••-----........•--•---•-•--...----------------------•-•--•---••------•-•----•---•--••-----......----... ------..._....
Date
Permit No......................................................... Issued.......677��
'------••-------
Date
THE COMMONWEALTH OF MASSACHUSETTS 4`
�. BOARD OF HEALTH
..................OF.... '`�'' ' /!' � ' .z° ................................
Trtifiratr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed,(�`') or Repaired ( )
by ' '�` �---- f�..- -------------- -----------........------•-----------------------------.........----------.........-•----------.......
•---a..-d-_•-•C •_•_
�'"� Installer��
at._.......�.>..4... /... 'l t^n/ ,� !L&........4•-- -fy s tom•''¢• .±!-} ------•-----•-•-------------•-------.........----------
has been installed in accordance with the provisions of TITLE: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.430.r//................. . . dated_-------_:....................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... .................................... Inspector--•- /�'/� �
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH p
N0'60 l„ z.... FEE,?.,!..............
Disposal Works nstrudion Prrmit
Permission is hereby granted...:_
*........•.F-......-...-------------------•----..._....------------•-•-••------...............------.......
to Construct or Repair ( ) an Individual Sewage Disposal System
x. - Y.::.... ---- .............................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
.......................................... -------------------------------------------------------------
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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LEGEND _ P
' EXISTJNG _ SPOT ELEVAT_.ION~' Ox0 �91aI BUfJ{KIS' CERTIFIED'f PyLQT `. Pt~ ; �1� :' Y
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EXlSTIN4 ;,CONTOUR -- - No.22162 .'
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APPROVED =� BOARD " OF HEALTH i y �
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x DATE
y AGENT'ar
SCALE °/`� 0 GATE
I' LDREDGE ENGINEERING CO. INd) G 'f��"c-er. y _ ' 'Y'
4 CLtENT ..___. I CERTIFY THAT `THE '±PROPO`lr� M
EGISTERE �REGISTERE01 JOB NO. 79 D b' BUILDING ' SHOWN ON :TH.�$ P '
t CIVIL ' LAND / �"
Y� CONFORMS TO THE ZONING AWE
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10-C A,T`ION 07- /� // SEWAGE PERMIT 0
VILLAGE
INST LLER'S NAME i ADDRESS ,
Lv
• U I l D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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9
zommonwealth of Massachusetts
= 5 Official Inspection Form
rFace Sewage Disposal System Form-Not for Voluntary Assessments
1:1°-Beldan Lane
Property Address-
ReaEProperty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Nvrm7s.Name
information Centerville MA 02632 6-23-09
required for
every page. State Zip Code Date of Inspection
ArprwWjon results must be submitted on this form. Inspection forms may not be altered in any
ii� I `ase see completeness checklist at the end of the form.
ImporWhen filling k-General Information )_
When filling out �.� r `�✓
forms on the
computer, use
'I `'�aspector:
only the tab key.- .. ..
to move-your ,.mph R. Smith
cursor-.do not Name of Inspector
use the return
key. `Stevens Construction, Inc.
any Name
P-0. BOX 71
-ompany Address
�Vlarstons Mills MA 02648
F14Q Gityrrown State Zip Code
508776-9054 SI 4994
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
jU&_-
q31D CMR 15.000). The system:
;0-Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-23=09
nsp s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health.or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to.the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
his 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.
Le9 710 1
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
e 5 Official Inspection Form
s b rface Sewage Disposal System Form -Not for Voluntary Assessments
11 Beldan Lane
-Property Address
ReaFProperty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Owner's Name
information is required for Centerville MA 02632 6-23-09
every page. Cityrrown State Zip Code Date of Inspection
&. Certification (coot.)
Ifrspection Summary: Check A,B,C,D or E/always complete all of Section D
4—Systern Passes:
® 1 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:
System was very clean and in good working condition. None of the failure criteria were existant at the
time of inspection for all of the components that were inspected. System passes and is ready to
receive flow.
13) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Cw', nonwealth of Massachusetts
e 5 Official Inspection Form
o rface Sewage Disposal System Form -Not for Voluntary Assessments
11~Beldan Lane
Prapp-rtyAddress
RealProperty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Oimer's.Name
information is required for Centerville MA 02632 6-23-09
every page. Cityrrown State Zip Code Date of Inspection
.A;ertification (cont.)
,:System Conditionally Passes (cont.):
Observation of sewage backup or break out or high static water level in the distribution box due
Jo 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 0 Y 0 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Cbmmonwealth of Massachusetts
Tie 5 Official Inspection Fora
-Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Beldan Lane
Pmp,erty Address
Reaf_Pro..perty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Ownees Name
information is Centerville MA 02632 6-23-09
required for
every page. Cityrrown State Zip Code Date of Inspection
B—Certification (coat.)
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,
`Vafety 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 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
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
ElLiquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
-Commonwealth of Massachusetts
5 official Inspection Form
-Subsurface rface Sewage Disposal System Form -Not for Voluntary Assessments
11 Beldan Lane
Property Address
ReaF1?-roperty Service Inc. C/O Thomas Parrott 195 Market St. Lynn, Mass.
Owner Owner.'s.Name
information is required for Centerville MA 02632 6-23-09
every page. Cityrrown State Zip Code Date of Inspection
B.-C ifecatlon (cont.)
--yes No
❑ ® Required pumping more than 4 times in the last-year NOT due to clogged of
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 of
tributary to a surface water supply.
❑ 0 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
❑ 0 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•09108 Title 5 Official Inspection Form:Subsurface Sewage p g Disposal System•Page 5 of 77
1
onwealth of Massachusetts
5 Official Inspection Form
.901 rface Sewage Disposal System Form -Not for Voluntary Assessments
11-6etdan Lane
Proputy-Address
Broperty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
OwnerName
information is required for Cantberuille MA 02632 6-23-09
-
every page. City/Town State Zip Code Date of Inspection
fir=checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
-ems 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?
ElHave 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?
ElWas 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-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
onwealth of Massachusetts
5 Official Inspection Fora
� ,%fisurface Sewage Disposal System Form -Not for Voluntary Assessments
11,$eidan Lane
FrZly'Address
R4a ?2mRerty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Q s-Name
information is required for GeOteiyille MA 02632 6-23-09
every page. Cityn-own State Zip Code Date of Inspection
P.-System Information
Desqription;
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
.11aundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ® No
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 3-1-09
Date
11,3 Commercial/Industrial Flow Conditions: .
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
1e 5 Official inspection Form
--$ rface Sewage Disposal System Form -Not for Voluntary Assessments
11 Beldan Lane
Property Address
ReaWroperty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Owner's Name
information is required for Centerville MA 02632 6-23-09
every page. City/Town State Zip Code Date of Inspection
q 1$ystem 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
-.-C .m:onwealth of Massachusetts
_ - 5 Official Inspection Form
a - bsu face Sewage Disposal System Form -Not for Voluntary Assessments
11 Beldan Lane
Prorierty Address
RearProperty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner O 's:.Name
information is required for Centerville MA 02632 6-23-09
every page. City/Town State Zip Code Date of Inspection
system Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
3a4--07 permit date on the town as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
p g feet
Material of construction:
cast iron . .0 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 150+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints are in good condition no evidence of leakage present.
Septic Tank(locate on site plan):
Depth below grade: 1.0
p g feet
Aaterial of construction:
0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1,000 gallon septic tank
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: ,, ' G,. `� �` "E��� 8'6"L x 4'10"W x 5'8" D
V 1
Sludge depth: 5„
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
e 5 Official Inspection Form
Sii face Sewage Disposal System Form -Not for Voluntary Assessments
SV.,y 11 Beldan Lane
Property.-Address
Rears, roperty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Owner's Name
information is required for Centerville MA 02632 6-23-09
every page. CityfTown State Zip Code Date of Inspection
1 .System information (cont.)
--- Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge Judge, Tape Measure, and
Probe
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping recommended on a 2-4 year regular pumping schedule as needed for regular O&M for
septic tank. Both Inlet and Outlet Tee's are in good condition and in good working order. The liquid
levels as related to the outlet tee invert is normal.The septic tank.itself is in good overall condition
and is structurally sound. No evidence of leakage was found during inspection.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete F1 metal ❑ fiberglass El polyethylene fl 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
-GoMmonwealth of Massachusetts
.__Ame 5 Official Inspection Form
- surface Sewage Disposal System Form -Not for Voluntary Assessments
1-1-Beldan Lane
-Prcperty Address
ReaF Property Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Oanwec's-Name
information is required for Centerville MA 02632 6-23-09
every page. Cityflfown State Zip Code Date of Inspection
®;system Information (coot.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
kp id 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
xonwealth of Massachusetts
5 Official Inspection Form
dace Sewage Disposal System Form -Not for Voluntary Assessments
11_—eldan Lane
arty Address
RLr.# operty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner O-utimies-Name
information is required for Ceinteryille MA 02632 6-23-09
every page. City/Town State Zip Code Date of Inspection.
..System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Liquid level in d-box was normal within respect
to the outlet inverts.
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.):
The d-box is level and is distributing flow evenly to both chambers(outlets are equipt with black flow
equalizers). No evidence of solids carryover present in the d-box. No evidence of leakage into or out
of d- ox was found during inspection.
-=Pump Chamber(locate on site plan):
mumps 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
. onwealth of Massachusetts
5 Official Inspection Form
o _- dace Sewage Disposal System Form -Not for Voluntary Assessments
1 l. idan Lane
Property Address
BeaL'Property Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Owners_Name
information is required for Centerville MA 02632 6-23-09
every page. Cityrrowrt State Zip Code Date of Inspection
stem Information (cont.)
; ] leaching pits number:
2-500 gallon
leach.ing..chambers number: chambers
❑ leaching galleries number:
] leaching trenches number, length:
❑ leaching fields number, dimensions:
Cl overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic:failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil is in good condition, no signs:of hydraulic failure present. Both leaching chambers had no liquid
in them, and the soil was dry. The vegetation over the leaching area consisted of a landscaped grass
lawn, and surrounded by oak and pine trees.
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Ctptnmonwealth of Massachusetts
e 5 Official Inspection Form
urface Sewage Disposal System Form -Not for Voluntary Assessments
11 Beidan Lane
'Property Address
Real.Property Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Owner's Name
information is required for Centerville MA 02632 6-23-09
every page. City/Town State Zip Code Date of Inspection
D.,S-ystern Information (cost.)
ComTents(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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
C: Monwealth of Massachusetts
ft 5 Official Inspection Form
o ----` ueace Sewage Disposal System Form -Not for Voluntary Assessments
Beldan Lane
Prop3tty:Address
Beal Plroper y Service Inc. C/O Thomas Parrott 195 Market St. Lynn, Mass.
Owner Qwvgi,s,Name
information is required for Centerville MA 02632 6-23-09
every page. City/Fown State Zip Code Date of Inspection
P �- stem 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
-AvteFe public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
re
S J
1�
y
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
t 5 Official Inspection Form
- S b.§k face Sewage Disposal System Form -Not for Voluntary Assessments
11 Beldan Lane
PropettyAddress
RealP.roperty Service Inc. C/O Thomas Parrott 195 Market St. Lynn, Mass.
Owner Owner's.Name
information is required for Centerville MA 02632 6-23-09
every page. Citylrown State Zip Code Date of Inspection
D. stem Information (cont.)
'e Exam:
Check Slope
EV Surface water
Check cellar
. Shallow wells
Estimated depth to high ground water: 50
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:
Obtained Mean sea Level Datum from USGS site
You must describe how you established the high ground water elevation:
Obtained Mean sea Level Datum from USGS site, and also referenced the Town of Barnstable GIS
site and checked the elevation of the property in which the title V inspection was conducted on and
checked it against the mean sea level datum.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
G mamonwealth of Massachusetts
Ve 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 --Beldan Lane
Prapeity Address
13eaFP?ro.perty Service Inc. C/O Thomas Parrott 195 Market st. Lynn, Mass.
Owner Owner's Name
information is required for Centerville MA 02632 6-23-09
every page. CityfFown State Zip Code Date of Inspection
-EAReport Completeness Checklist
M -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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
M
a
TOWN OF BARNSTABLE
LOCATIG'N ..j 1 ic�cxr, t-cinC SEWAGE# ?DQ7Z '71
VILLAGE anJzr u', ASSESSOR'S MAP&PARCEL 199 31 - 001
INSTALLERS NAME&PHONE NO. R � 53 �xcaycz-tro+�
SEPTIC TANK CAPACITY /pOO qa 1
LEACHING FACILITY: (type) S_op o cx I cAQ rn (z) (size) 13 x ,2?S X
NO. OF BEDROOMS 3
OWNER
PERMIT DATE: - / - p T7 COMPLIANCE DATE:
Separation Distance Between the:. j
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
Al 28 S
Az - 3z J
[32 SS {
A3 - 4Z 6 Rcnx �wc►l ;ng
f33 - 9CCK B
AL4 - �5 �..
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7 r •T,
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MON
GommonweoM of Massachusetts 4 p '"s
RJqm Gi
Executive Office of Environmental Affairs D.E Tifle Ittspector
De artment of 'lam, Tq�Vic?9
Environmental Protection TeatTiet,�IA 02536
t titR y, ,,
(508
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPART A
i5 ~z
CERTIFICATION APR .1
1997
Property Address:
11 Beld�n Lane Centerville Address of Owner: T O HrAt Hp ASTABLE ~
Date of Inspection:3111197 (if different)
Name of Inspector:John Gracl Kevin Murphy:63 Newbury St.Lowell Ma.01 5 qr w`r
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This Inspection Is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Fur714�
aluation B the Local Approving Authority performing at the time of the Inspection.My Inspection does
Y pp 9 tY not Impty any warranty or guarantee of the IongevttV of the
Falls septic system and any of its components useful life.
Inspector's Signature: Date: VOW
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair, passes inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.)
_ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiitration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St Lowell Ma.01851
Date of Inspection:3111197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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 the public health, safety and the environment.
1} SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply. I
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St Lowell Ma.01851
Date of Inspection:3111197
D] SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/15195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CH ECLIST
Property Address: 11 Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St Lowell Ma.01851
Date of Inspection:3111197
Check if the following have been done:
X Pumping information was requested of the owner,occupant,and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
n►aAs built plans have been obtained and examined. Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St Lowell Ma.01851
Date of Inspection:3111197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 gallons
Number of bedrooms: 2
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n1a
Last date.of occupancy: Oct.1996
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the year.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1980
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St Lowell Ma.01851
Date of Inspection:3111197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"w 4'10•
Sludge depth:3'
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:2'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 16'
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping system every one to two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
n1a
(revised 11115/95)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St Lowell Ma.01851
Date of Inspection:3111197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla
Material of con struction:_concrete_metal_FRP_other(expIain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nla
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
nla
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
n1a
(revised 11115195)
7
F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St Lowell Ma.01851
Date of Inspection:3111197
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
ria
Type:
leaching pits,number: 1,000 gallon[each pit
leaching chambers,number:nfa
leaching galleries,number: nfa
leaching trenches,number,length: nla
leaching fields,number,dimensions:nfa
overflow cesspool,number:n►a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The overflow is structurally sound and functioning properly.it was empty at the time of the inspection.it has been 112 full.
CESSPOOLS:
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: nfa
Depth of scum layer: nfa
Dimensions of cesspool: nfa
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nfa
PRIVY:
(locate on site plan)
Materials of construction: nfa Dimensions: nfa
Depth of solids: nfa
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
nla
(revised 11115195)
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: "Belden Lane Centerville
Owner: Kevin Murphy:63 Newbury St.Lowell Ma.01851
Date of Inspection:3111197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
1
v �►
�3
❑ � OpV
AA 36
A6 35
EA q
6n 117
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
FORM 30 C&W HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY/TOWN
b
DEPARTMENT
ADDRESS 1 q( e,q
,M SVByOw TELEPHONE) b�"
Address t �hA 'Occupant _
Floor Apartment No. No.of Occupants
No. of Habitable Rooms No.Sleeping Rooms
No.dwelling or rooming units No.Stories
Name and address of owner __
Remarks Reg. Vio.
YARD Out Bld s.: Fences: C_E. i-,LL (J 6^5 TU Aj 4;q 5R-& k.,,fJ Garbage and Rubbish d, r- S-tj 5-C 1,JOL 17&Z A\
Containers: J
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimne
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairw j
Obst'n.:
Hall, Floor,Wall, Ceiling:
Hall Lighting:
Hall Windows.-
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
14 A-
- TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s
ELECTRICAL Panels, Meters,Cir.: !
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect..-
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin, Shower or Tub:
Infestation Rats, Mice, Roaches or Other.-
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIErUny.INSPECTOR TITLE
.M
DATE I TIME �� " P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION /C, /�' P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
i
SYSTEM PROFILE NOTES o 0
TOP FNDN. AT EL. 58.0
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE)
ACCESS COVER TO WITHIN 3" OF FIN. GRADE 1. DATUM IS APPROXIMATE NGVD
' ACCESS COVER (WATERTIGHT) TO �c ah `o w�
56.5 MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6 OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING 'Ck ��a Lake2% SLOPE REQUIRED OVER SYSTEM 55.8'
INSTALL INLET* ABOW RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
• *EXISTING OOULET INVERT FOR FIRST 2' OR GEOTEXTILE FABRIC I_
3 MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
**E7(ISTING 1000 * , H- 10
*EXISTING GAuoN SEPTIC TANKs7 7
6" SUMP 52.8'
BAFFLE 52.22' �� 52.05' 5. PIPE JOINTS TO BE MADE WATERTIGHT. �\ Route 28
0 52.0' a p p a p p p Q 0 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH
4' 6" CRUSHED STONE OR MECHANICAL 0 0 0 L] 0 0 0
DEPTH.OF FLOW = COMPACTION. (15.221 [2]) 2' 0 0 0 d MASS. ENVIRONMENTAL CODE TITLE V. LOCUS
TEE slzEs: 0 50.0'
INLET DEPTH - 10" „ 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
OUTLET DEPTH = 14" 3/4 TO 1 1/2 DOUBLE WASHED STONE BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
( 13 X SLOPE) ( 1 X SLOPE)
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
FOUNDATION EXISTING SEPTIC TANK 19' D' BOX 7' LEACHING
FACILITY 5' 9.WITHOUT OINSPECTION BYNENTS NOT BOARD BE OFHEALTH AND LLED OR CPERMISSION LOCUS MAP
*THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. OBTAINED FROM BOARD OF HEALTH. SCALE 1"=2000'f
;LOCATIONS OF ALL UTILITIES AND ALL SEPTIC TANK SIZE AT 1000 GALLONS AND 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING ASSESSORS MAP 189 PARCEL 31-001
BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY FOR RE-USE
PRIOR TO INSTALLING ANY PORTION OF DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION
SEPTIC SYSTEM BOTTOM TH-2 EL. 45.0' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO LOCUS IS WITHIN AP OVERLAY DISTRICT
COMMENCEMENT OF WORK.
LEGEND 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
\ REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
100.0 PROPOSED SPOT ELEVATION \ 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
Aso \\ REMOVED 5' BENEATH AND AROUND THE PROPOSED
+100.00 EXISTING SPOT ELEVATION \ LEACHING FACILITY.
100 PROPOSED CONTOUR G �� \\
<; *S� � \ SYSTEM DESIGN:
100 EXISTING CONTOUR >s •o \ oNE
GARBAGE DISPOSER IS NOT ALLOWED
G' \
- ONE /ONE \\ DESIGN FLOW. 3 BEDROOMS ® 110 GPD = 330 GPD
9 S6' \ USE A 330 GPD DESIGN FLOW
tk \� SEPTIC TANK: 330 GPD (2) = 660
EST HOLE LOGS d EXIa11NG 3 **RE-USE EXISTING 1000 GAL. SEPTIC TANK
BR,DWELLING LEACHING:
ENGINEER: DAVID FLAHERTY, R.S. BENCH MARK - CORNER OF TOP OF FNDN
CONC. BULKHEAD EL. = 58.0 EL•'58•0' �00 SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD
WITNESS: DON DESMARAIS, R.S. ��1' BOTTOM 25 x 12.83 (.74) = 237 GPD
DATE: FEBRUARY 22, 2007 a�
o, TM-+ ,F,_2 C TOTAL: 472 S.F. 349 GPD
PERC. RATE _ < 2 MIN/INCH •, :..-:y.--+_�,,.; •:, � \
11659 0 0 10 OR�� \ �� USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
CLASS i SOILS P# :~ n� � >>> \\ WITH 4 STONE ALL AROUND
ELEV. ELEV. \
0" 56.0' 0" 56.0' Z6css \
.• \F A Lp \ APPROVED DATE BOARD OF HEALTH MA
10YR 4/2 FILL
6" 55.5' 18" 54.5' S� \
B k\ \\
LS
S x\-i' TWIN 24" OAK \\
28" 10YR 6/8 53.7' " 10YR 4/2 \.r \ TITLE 5 SITE PLAN
24 54.0 OF
B 2�3 S2Cn
C LS 11 BELDAN LANE
PERC 1OYR 6/8 (CENTERVILLE) BARNSTABLE, MA
38 52.8 ` PREPARED FOR
MS
B & B EXC./ ROBERT PIERCE
2.5y 7/4 ,, \-► ���ry/i' DATE: FEBRUARY 23, 2007
MS v
�ZH OF MAg •�\ h�
H OF, -3 -
" " � ARNT N tiN �� ARNE tiN k�
2 5 7 4 fo 508 6 9880
120 46.0 132 Y / 45.0 0 01F . :. m 1
CIVIL JA�A
NO. 307g2 No.26348
NO GROUNDWATER ENCOUNTERED �0) �0R o�P 0 Z down cape en gin eeririg, in c.
Q/STSf' Essa ���
„ 410. i c�C� 19N� RVE CIVIL ENGINEERS
Scale: 1 = 20 i
�[ q3 �jDOy LAND SURI/EYDRS
of / 939 Main Street - YARMOU THPOR T, MASS.
DCE #07-022' 0 10 20 30 40 50 FEET DATE ARNE H. OJALA, P.E., P.L.S.
07-022 B & B_PIERCE.DWG (DDF)