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HomeMy WebLinkAbout0008 BUCKSKIN PATH - Health S Buckskin Path ;3Centerville .. A= s i /// 5 M E A D No.Z-IWWR UPC 126U smaad m • W&In U" OIN .,,. ,�►■olom Commonwealth of Massachusetts �90"00-�" F4,Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path t4ri Property Address Alyssa McInnis , Owner Owner's Name ? information is °a required for every Centerville Ma 02632 11/24/2018 ,•,, page. City/Town State Zip Code Date of Inspectio; Ya� 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 filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co � Company Address Centerville Ma 02632 City/Town State Zip Code law 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com 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 addre ss . 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 11/24/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �e = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown 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: The dwelling located at 8 Buckskin Path Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 rows of 6 ARC 36 HC Chambers. The system was found to be in proper working condition at the time of inspection. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms 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 distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form JIo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 hand Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 El ® 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown 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 '/2 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. ❑ ® 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. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts I� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown 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 volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® 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? ❑ 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: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: 15m.p.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: system installed 7/1 512 0 1 1 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner Name e information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 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 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 12 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 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 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 rows of 6 ARC 36 HC Chambers in 30' trenches. Leaching facility was video inspected and was found dry with no signs of past overloading. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection 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 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 z•3�.5 �(c 3-IM; !_ _ S-3-H n 3-405 q_ 73 T 1ACKoF IioosF #t t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Alyssa McInnis Owner Owner's Name information is required for every Centerville Ma 02632 11/24/2018 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. ® B. 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 15: Explanation of estimated depth to high groundwater included t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r __�' ' i TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner r��^�/' --D-111— Tenant P Oz�Address 1-5 U Address w A- complia= Remarks or Regulation # Yes O Recommendations 2. Kitchen Facilities V _ 3. Bathroom Facilities v "x�.. �'. 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use - 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed ' f (� j ( G � Z PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here No. �� � � � ��—' Fee / THE Cn- MMQNWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYication for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(-1/U'pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 91Wb1A1N"V&All Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ( _ p AA C C_`'0 1 tV N e Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size /A 7SS— sq.ft. Garbage Grinder( ) Other Type of Building 1100!�If No.of Persons /' Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 30 gpd Design flow provided 316 i l gpd Plan Date 7/iC�i/ Number of sheets Revision Date Title Size of Septic Tank /s®® A) Type of S.A.S. A(C 3 G J4(, Description of Soil Nature of Repairs or Alterations(Answer when applicable) eel--t C 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 o Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. I' -�o� �j Date Issued 771 Q i (' - obi ,: �- --- 10 t No. O .: '' Fee /THE C�r M.M NWEALTH OF MASSACHUSETTS Entered�nooinpntet: ✓ , PUBLIC HEALTH'�DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes application' for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon•( ) [:]Complete System ❑Individual Components Location Address or Lot No. 91 ocvsS IN TC,4) Owner's Name,Address,and Tel.No. '� M( C:i.H INN EI Assessor's Map/Parcel � ( ® — OQ j Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. D:X1)01C.') R 15(Ow ',) - SCO-LIM- / �N �Nrr✓In t�Wc5 s-09177- 5-3/ Type of Building: Dwelling No.of Bedrooms "3 Lot Size /415 7S'S sq.ft. Garbage Grinder( ) Other Type of Building �IUUS r' No.of Persons / Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required). 3 30gpd Design flow provided :3'/G i 3 gpd Plan Date 4k / Number of sheets Revision Date Title Size of Septic Tank /5'00 A)C—0 Type of S.A.S. A t[ 3 G N c. Description of Soil Nature of Repairs or Alterations(Answer when applicable) I N 5 t 0� !V EW -J I fi S S of vO+ I C I 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 o Health. Signed Date 1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. t/ Date Issued 7 ---------------- ---------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance /THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( � Upgraded( ) Abandoned( )by a-1ct5 At lei(y,,j,j Tn)C at VC S1c t N ��(k has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated `- ) Installer�x 4-1 ( A tt N ni C Designer /V S N Y r✓ �'( NG CS #bedrooms '3 Approved design flow f!i a gpd The issuance of this permit shall not be construed as a guarantee that the system will �tio aMesigned. Date / Inspector .----------------------------------------------------------- ---------------------- ------------------------------- No. f, / Fee CQ) ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at F C IC S,(t w) TG.F r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be comj leted within three years of the date of this permit. / Date 1 \ Approved by V V — vv� C Town of Ba 66.le Re0. atery Services Thomas.F.Geiler,Director Pubcea Divs n Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: Sewage Permit# cW/" ae:V;, Assessor's Mapfflarcel AO _QC—? Installer&Desion�Cer fig Form Designer: E7Y%f,, , . r• W o r 4 s, Inc . Installer: •���''�n �- Address: Jz W. C.ra, s s :e 1¢l 'IZd Address: Q t 34 t.� A- oZ� y ����rJktU Y'ht4 4'ZG3Z. On p� < �r��n �, was issued a permit to install a (date) r"0 (installet) septic system at JS n 40-k based on a design drawn by (address) 'J,L+e_✓ T Mc- &4L dated r7 Z— dew -1 rZ J � (designer) ,O,, I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation:of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' 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 as-built by designer to follow. Stripout(if required) w. _ eted and.the soils ere-found satisfactory. PCTER T. -- - MCENTEE 41�, ler's Signature) CIVIL No:35 09 9�bIgT� O 4r�' (Designer's Signature) (Affix Design PLEASE.RETURN TO BAIZNSTABLE PUBLIC HEALTH DWISI OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM BUILT CARD-ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice formsWesipmcrtification forrn.doc TOWN OF BARNSTABLE LOCATION 18 S SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL -607 INSTALLER'S NAME&PHONE NO. A— —.% h� SEPTIC TANK CAPACITY /SQC3 A)et, 3 LEACHING FACILITY.(type) q& IG 4 C (size) :2 30" M&AE-K NO.OF BEDROOMS _S OWNER e l PERMIT DATE: OJT)/ COMPLIANCE DATE: � 1-5 �/ Separation Distance Between the: 60 " ,-A^s s ki 9 S Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility / O GLOa4- ! (aFeet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 260 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ���f�tx9 e.�i �� � � ►@ CIS' ` - 73 T Ac K Q Y li 605 s J; oFtHeroh, Town of Barnstable Barnstable Regulatory Services Department ' [SAFtNSTABLE, ' � " 39. Public Health Division pr i639• a�� m F°MAC 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 55606 July 13, 2011 Barbara Mcelhinney 8 Buckskin Path Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at, 8 Buckskin Path, Centerville, MA. was last inspected on 6/03/2011 by Patrick M. O'Connell, certified septic inspector for the State of Massachusetts. According to the private septic system inspector, the system "Fails" due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. • System is in hydraulic failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period may result in future enforcement action PER ORDER 0.F-Q, E BOARD OF HEALTH L Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the I computer,use 1. Inspector: only the tab key I to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 reN^ City/Town State Zip Code 508-428-1779 SI 12855 _ Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes — ® FaiW. C) ZE ❑ Needs Further Evaluation by the L cal Approving Authority t ° AAo Y^S 3 June 3, 2011 Job# 11-9,6 =' I ector's S atu a Date : The system inspector shall submit a copy of this inspection report to the Approvind Authority��8oard,,� of Health or DEP)within 30 days of completing this inspection. If the system is a shared sys}}—em 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. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 L/1 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path _ Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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) 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): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is Centerville MA 02632 June 3, 2011 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '( 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is Centerville MA 02632 June 3, 2011 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ` ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is Centerville MA 02632 June 3, 2011 required for every page. Citylrown State Zip Code Date of Inspection D. System Information Description: 1 � Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Cesspool pumped every other year. 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): 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 l - Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is Centerville MA 02632 June 3, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration One 12" Depth—top of liquid to inlet invert 6" Depth of solids layer 4" Depth of scum layer Dimensions of cesspool 6x6 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. Cilyrrown State Zip Code Date of Inspection D. System information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Observed staining to within 6"of inlet pipe. Single cesspool automatically fails per town standards. 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.): 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ Title 5 Off -ci;al Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address — McElhinney Owner Barbara information is — ------------------------Owner's Name required for Centerville —_ _— _____ __ MA 02632 June 3, 2011 every page. cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below �1 drawino attarheri sanarntPh, . . . . . . . . . . . . . . . . . . . ♦ ♦ ♦ ♦ \ ♦ \ \ \ ♦ \ ♦ \ ♦ \ ♦ ♦ \ \ ♦ ♦ \ \ ♦ ♦ \ \ ♦ ♦ ♦ 39 50 Back Yard Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is required for Centerville MA 02632 June 3, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: N/A feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Buckskin Path Property Address Barbara McElhinney Owner Owner's Name information is Centerville MA 02632 June 3, 2011 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Town of Barnstable P# /3 3-:�- / Department of Regulatory Services Public Health D' aasrrsr,►sr,� _ t, 1vIlS10I1 Date _. 200 Main Street,Hyannis MA 02601 Date Scheduled 1 C�C�-CAO Time � Fee rd. Soil Suitability Assessment for Sewage Disposal Perforrned B n y: � � o `C'"Cvt 4-ev- Witnessed By:. LOCATION& GENERAL INFORMATION Location Address (gcr�CC�4 .�. tt t` Owner's Name Address S tA.'.n 10c k-(1 (fe-V LA- a 2 CO 3'z Assesspes Map,'Parcel: / © -00 7 Engineer's Name-'RA-ev Kq-;-i kx NEW.CONSTRUCTION •REPAIR Telephone# 737 16 F Land,Use t�+Ccl I Slopes(4'oj Z— .Surface Stones �/¢ Distances from: Open Water Body Z ft Possible Wet Area ft ft Drinking Water Well' ft Drainage Way Z ft Property Line Z° -` ft .Other ft -'SKETCH:(Street name,dimensions of lot,exact locations of test holes&.perc tests,locate wetlands,in proximity to holes) i Parent material(geologic) Depth to Bedrocit kJL41 Depth to Groundwater. Standing Water.in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater % 3 Z', DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _ in, Depth to sell mottles: In, . -Depth to:seeping fmin side of obs.mole: in, groundwater Adjustment Index Well.# Reading Date: Index Well level...q,,,,,,a,,.,, Adj,factor—Adj.Groundwater Level PERCOLATION TEST Hate , ThIle,Y.� Observation Hole# Time at 9" Depth of-Pero ✓� � 24 3- r-0-5 Time at 6" Start Pre-soak Time @ M� 'rime(9"•6") End Pre-soak Rate Min✓Inch Site Suitability Assessment: Site Passed--,—/ — . Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be.conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S2PTI0PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munselq Mottling (Structure,Stoneg;Boulders. Consite ' Gravel) D SL to DEEP`OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,.Boulders. Consistency,%Gravel) Q -�o A as vatL l(l �- /O 2� 3 Z_ P—C- 5`j Z`S y f ?- Gar DEEP OBSERVATION.HOLE LOG. Hole# Depth from. Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselq Mottling (Structure,Stones,Boulders. Consistency. r DEEP OBSERVATION HOLE-LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselq Mottling (Structure,.Stones,Boulders. Consistency, Flood Insurance Rate Map: f Abovd-5,00 year flood boundary No_ Yes Within'500 year boundary No ,v Yes Within 100 year f1bod boundary No K Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio s material exist in all areas observed throughout the area proposed for the soil absorption system? T-C� -- If not;what is the depth of naturally occurring pervious material? Cerhflcation I certify that on lLl kCL (date)I have passed the soil evaluator examination approved by.Ahe Department of Environmental Protection and that the above analysis Was performed by.me consistent with . the required ` ' ing,expertise and experience described in 1310 CMR 15.017. Signature Date Z( � l� Q\SEpnC�PBRCPORM DOC r rr, t4 PROPOSED S.A.S. 4-EGEND cao 2 TRENCHES N C PROVIDE INSPECTION x 100.98 EXISTING SPOT GRADE F PORT ON EACH TRENCH I ®Nouset Ln—— —— EXISTING CONTOUR Tomahowk 0< stockade OVERHEAD WIRES 7 LOCUS S 86'S9:30" W _ -- —- — —'_�`- W EXISTING WATER SERVICE Powderhorn woy oa 100,63 0 115.00' �� f/ J� C EXISTING GAS SERVICE x 1 0.56 TEST PIT �\ Dee 'r 9 S\oney x 101.92 ?� \ \ BENCHMARK C fi�(9 SHED 8 4 r, O y ! �O 100,35 SPIKE`�t� � � o � Q Route Z 1Q�90 � `TP-2 < LOCUS MAP la2 ,o1 PAl/ED - ` GENERAL NOTES: NOT TO SCALE / PROPOSED SEPTIC TANK 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL t ) 102,10 x 102.39 �, m 1500 GALLON CAPACITY BOARD OF HEALTH AND THE DESIGN ENGINEER. EXISTING CESSPOOLS 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 100.18 tl '� �� I -�, o TO BE PUMPED, FILLED W/ OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE BM 101,63 � ( �I ��� SAND & ABANDONED LOCAL RULES AND REGULATIONS. Cb '. Q02 8 �O� 101,92 l _�/ I gR, (SEE, ALSD, NOTE 19) q3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR U t 5 G Q/ 1 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 11 O DESIGN ENGINEER. C 1 , �DECK 0 2. A 9 82 BENCHMARK SET 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING ^ ' `ry �`� Outside Coy. of bulkheod FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN i p h ENGINEER BEFORE CONSTRUCTION CONTINUES. i �•.G�s EXISTING G' z EL.=102.47 (Assumed) � o 102.34. HOUSE 8 02, ^ .Q I I 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. U) <# >i � ) T.O.F.-103.47E �� � i � , � 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF I PA 11E.L `rS I i rn I o THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF CD p I I Q HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. DRI VEWA Y'. 102,2 8 G� Z S EXIST. SEWER 101,1�/9 i I Wo 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. IN I/=100.55E I 1 t 101,42 \\ 10119 i g 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 1� LAMP \� �/ i x 9�35 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE T DIRECTED BY THE APPROVING AUTHORITIES. V 99.92 i I �\ S-y� t 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 0� i THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING i I LOT 43 101.90 X�o�--==- .y 15 CONSTRUCTION. 1 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS I I , APN 190-007 _ 101,06 I IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 16 755tS.F. '� — \ I REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). CBN /DH ' �' —_x 1,0114. I 9 ,.79 1 102,31 © x 100.11 100.72 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE I a - I INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. \p� i 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND ox 99.7&_ y •�I IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. ?Ix 101 � OF MA 101,56 67 i `��` �P��� ssgCy PLAN REVISIONS \�� • ` j / \ o PETER T. G� 7/12/11 — CORRECT CREDIT AREA PER LINEAL FOOT FOR Arc36HC. i \ g McENTEE 7/14/11 — REVISE TRENCH LOCATION DUE TO SECOND CESSPOOL FOUND . 99,50� � o CIVIL 100 12 OOO �.�, split rail fence 85. 0' YDRANT a. 35109 �N 86'S '30" E A��F EGISIE B/DH PROPOSED SEPTIC SYSTEM UPGRADE PLAN /DH P SS/ E 8 BUCKSKIN PATH, CENTERVILLE, MA 99.47 of pavement C (ltrIt1 Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 edge 99.50 ) 100.22 OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO. PO WDERHORN WA Y MCELHINNEY, ROBT. W & BARBARA L Engineering Works, Inc. 1"=20' P.T.M. 178-11 8 BUCKSKIN PATH 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. CENTERVILLE, MA 02632 (508) 477-5313 7/2/11 P.T.M. 1 of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED / ! FINISH GRADE SHALL NOT BE < EL.99.3 EXISTING FOR A DISTANCE OF 15' AROUND THE HOUSE 8 PERIMETER OF THE S.A.S. T.O.F.=103.47 SEPTIC TANK PROPOSED D—BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT INSTALL INSPECTION PORT OVER END UNIT BACK OF HOUSE' Or' T.O.F. OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE EXISTING F.G. EL.=101.0t F.G. EL: 101.5t F.G. EL: 102.3(MAX.) MAINTAIN 27 GRADE (MIN.) OVER S.A.S. DECK L = 2( L = 6' L = X N . �+ O S=1% (MIN.) p S=1% (MIN.) @ S=l%1% (MIN.) INSPECTION PORT 4"SCH40 il PVC 4"SCH40 PVC 4"SCH40 PVCif 1 A8' __„ 6" 10.75" TO ---- TRENCH ] INV.=100.15 48" LIQUID INVERT T LEVEL ADD INV.=98.90 GAS BAFFLE INV.=99.27 PROPOSED INV.=99.10 2 ROWS OF 6:UNITS AT 5.0'/UNIT)= 30' j INV.=99.90 D—BOX SOIL ABSORPTION SYSTEM (PROFILE) p FL S.A.S. LAYOUT L____ TRENChi______2.8' PROPOSED SEPTIC TANK ESTABLISH VEGETATIVE COVER 30'----{ TIE IN TO EXISTING SEWER BACKFILL WITH CLEAN NATIVE OR AT HOUSE, INV.=100.EWE PERC SAND TO TOP OF CHAMBERS 15.5_. �' 2„ _ NOTES: s• 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP ELEV.=99.33 INVERTS, PRIOR TO INSTALLATION. INV. ELEV.=98.90 �-, 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND BOTTOM ELEV.=98.00 15.5 12" " 1, TRUE TO GRADE ON A MECHANICALLY COMPACTED 2,g3' 2.83' � 6" 8" SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 5' MIN. ABOVE BOTTOM OF 14' A 3) INSTALL INLET & OUTLET TEES AS REQUIRED. T.P. EXCAVATION OR G.W. 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE EXISTING SUITABLE 3 OUTLETS — H-10 LOADING 2" AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. NO G.W., EL=90.6 z MATERIAL D—BOX USE 2 ROWS OF 6-ADS Arc 36HC UNITS SEPTIC SYSTEM PROFILE IN TRENCH CONFIGURATION WITH NO STONE 63.25" N.T.S. TYPICAL SECTION 1 s" DESIGN CRITERIA SOIL LOG 34.5" DATE: JUNE 21, 2011 (REF#13,321) NUMBER OF BEDROOMS: 3 BEDROOMS SOIL EVALUATOR: PETER McENTEE PE SOIL TEXTURAL CLASS: CLASS I WITNESS: DONALD DESMARAIS R.S. HEALTH AGENT TOP VIEW DESIGN PERCOLATION RATE: <2 MIN/IN ELEV. TP- 1 DEPTH ELEV, TP-2 DEPTH —60„ DAILY FLOW: 330 G.P.D. 101.7 A 0" 101.6 A 011 END CAP END CAP SANDY LOAM SANDY LOAM FRONT VIEW SIDE VIEW DESIGN FLOW: 330 G.P.D. 101.2 810YR 4/2 6, 101,1 B10YR 4/2 6 REAEND R/TOP VIEW GARBAGE GRINDER: NO SANDY LOAM SANDY LOAM NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW LEACHING AREA REQUIRED: (330) = 445.9 S.F. 10YR 5/8 10YR 5/8 TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY .74 99 0 C1 32" 99.1 C1 30" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY PERC 4640 TRUEMAN BLVD 36"/,48" ADVANCED DRANAGE SYSTEMS,Ems. HILLIARD, OHIO 43026 Are 36HC DETAIL d PROPOSED D—BOX:: 1 INLET, 3 OUTLETS, H-10 RATED M-C SAND M-C SAND SOIL ABSORPTION SYSTEM 20 GRAVEL 20 GRAVEL 6/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE ADS Arc 36HC UNITS IN STONELESS TRENCH CONFIGURATION 8 BUCKSKIN PATH, CENTERVILLE, MA (GENERAL USE APPROVAL FOR 7.79 SF/LF IN TRENCH CONFIGURATION) Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 2 x 30' TRENCHES = 60' 90.7 132" 90.6 132" Engineering by: SCALE DRAWN JOB. NO. 60' x 7.79 SF LF = 467.4 SF Engineering Works, Inc. NTS P.T.M. 178-11 / PERC RATE <2 MIN/IN. ("C" HORIZON) g g NO GROUNDWATER ENCOUNTERED 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74(467.4 S.F.) = 345.9 G.P.D. (508) 477-5313 7/2/11 P.T.M. 2 of 2