HomeMy WebLinkAbout0298 CAP'N LIJAH'S ROAD - Health 298 Cap'n Lijah's Road
Centerville F/R
A 193 111 "
I
No. 42101/3 ORA
ESSELTE
10%
mum
%JUIVIMVN WEALTH OF
' MAssacxusETTs
EXECUTIVE OFFICE OF ENVIRONh(ENTAL AFFAIRS DEPARTMENT OF]ENVIRONMENTAL PROTECTION
3h jol
OFFICIAL INSPECTION FORM TITLES v�
SUBSURFACE SEWAGE DNOT jSp0 S��VOLUNTARY ASSESSMENTS
PART A TEM FORM
CERTIFICATION
ProPCHY Address:
Owner's Names v ,j `.
Owner's Address:
Dab et lnepKyon:
Name oflnapecbr• le
Company Name; pr t
Ming Address: v , $
r-�
Telephone Nnmber; p - 3 U A - -0'7 6 4�
CERTIFICATION STATEMENT
I cestw that I have _
PLOY the disposal
below is true,accurate sad complete as of the ' � system at this address and that the '
atrapproved
rod stem ence is the hme of the inspection,The inspection was information reported
approved system Inspector Prof-fiction and maintenance of on site sewage performed based on my
pnrsnantlto Section ISJ40 otTide S(310 C11M 13.000).no a D8p
�L passes
Conditionally Passes
Needs Faija
Further Evaluation by the Local Approving Authority
Inspector's Signature
Date: D 0 3 01
The system inspector shall sub hru a co '
DEP)within 30 daysCOPY of this inspection
of completing this inspection.If the s report b the Approving Authority(Board of Health or
gpd or greater,the inspector and the system owner System is a shared system or has a design DEP.The original should be sent to the system owner ll submit the report to the flow of 10,000
authority. and copies seat to the buyer, ropriate regional
o�of the
i 11 if applicable,and the approving
Notes and iomahenta G, eG 1
vv
�j�-S- O�d
+►►is�a report O
P my describes conditions at the time of inspection and under the conditions of use at t
time.This Inspection does not address how the system w1p perform to the future undo
conditions of use. hat
r the same or different
Tide S laspection Form 6/15/2000
page 1
ti
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART A FOB S
CERTIFICATION(continued)
Property Addrear.==L�� -� i, �S
Owaera
Date or�pecaons
Inapectlo■Summary: Check AAC,D or s i
ALA eomPlete AU of Section D
A. System Passma
I have not found any WOustion which
s dim
15.303 or in 310 C x 13.304 exist,Any�y��a� �° ariWabed is 310 CMR
Co bs not � de
�0
v e
9. System Conditionally Passes:
One or more system components as did in the"Conditional Peas"Tbs systm upon Completion of the replacement or repair)as app�d�wmof�tk will�.
Answer yea,no sot determined(Y,N,ND)in the
explain• the following edEemenb.If.,not
determined-please
��d, septic exhibits teak is tat and over 20 years old*or the septic tank whether meprl
n or exSltration or tank failure b ( �)is structurany,
exis�8 tank is replaced with a 1 . .,Sys will pass inspection if the
• metalseptic tua _ Y�septic tank u approved by���,�HeaW
indicating �less than 20 n if it is strvctUISITY sound,not and if a
old is avaiLble. Cerd&ate of Compliance
ND explain:
Observation of sewage backup or break o o static water level is the distribution box
obstructed pip*)or due to a broken.settled uneven due to broken or
approval of Board of Health): 'on box.System will past inspection if(with
ken pipe(s)are replac
obstruction is removed
distribution box is leveled or replac
ND explain:
P
The tern required Pumping more than 4 times a year due to broken or obstruc
lion if(with approval of the Board of Health): ipc(s).The system will
broken Pipe(s)are replaced
obstruction is removed
ND explain:
Titl,s i '"nm"An P^rm 4/1cnnnn 2
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S
PART A
CERTIFICATION(continued)
Property Address: 2 C
Owner:
Date of Inapeedom
C. Further Evaluation V Required by the Board of Health:
\ Conditions exist which require tinther evaluation by the Board of Health in order to determine if the ystem s
is g to protect public health,safety or the environment,
1• In will pass unless Board of Health determines in accordance with 310 CM>it l� i Is not functioning m a maoner which will protect public )��the
��.safety as 'the euvlroamentt
1 or privy is within SO Leaf of a gurfum water
1 Of privy is within 50 feet of a borderiop vegetated wedand or marsh
L System win fan anleq a Board of Health(and Pub11e W ter
system is functioning in a or that protects the public safety per'if a°r environment:
nee that the
_ ety and environments
110 system has a septic mad soil a (SAS)and the SAS is .surfm water supply or inbutary a surBce wa ly. within 100 feat of a
_ The system has aseptic tank and the SAS is within a Zone 1 of a public avatar supply,
— The system has a septic tank and the SAS is within SO fact of a private water supply aro1L
s�m hs A���c SAS and SAS is less than 100 feat but SO feet or more flnm a
supply used to de distance
"This system passes if the u water analysis,pert at a DEp certified inborn
bacteria sad volatile compounds indicates d mt well is free lrom �'for conform
the presence of nitrogen nitrate�� pollution from that heinty and
failure criteria are tri erect,A c �°u b or lei than S ppuq provided that no other
opy of the analysis moat be a led to this form.
3. Other:
Ti�l� C ►non��finn Rnr�..�G11 C/'1/�/1�1 3
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
FOtM
PART A
CERTIFICATION(continued)
Property Address: 2 7 L •"4�S
Owner
Date of Inspection:
D. System Fallon Criterfa applicable to an ryrtemr.
You=M indica0e'�+�ea"Of"w"to each of the following for jLkspectionL
Yea No
Backup of sewage into facility or system co
ADischarge of
Pow otefHuent to the surface��due to overloaded or clogged SAS or cesspool
clogged SS or compoolthe ground or urfwG waters dub to as overloaded or
cesspool
level in the distribution box above outlet invert due to an overloaded or cloned
SAS or
Liquid depth is cesspool is less than 6"below invert or available volume is less
Jotday flow
�pumped PUMVing e°0n than 4 times in the last year Endue to clogged or obi Pis)•IVun>ber
-� Any Any Pam of the SAS,cesspool er PnV is below high pound water elevatic,
wow Mvply.pindon°f cesspool or privy u within 100 Beet of a mr&cc water supply or tributary M a surface
Any Patios of a cesspool ar privy is wig a Zone 1 of a public weL
j Any Amon ofa cesspool or privy is witch SO feet of a pdvate water
Any portion of a cesspool a privy is less than 100 feet but �f w°n'
mPPlY well with no quality �than n feet fkOmthe a
Performed at a DEprgped labontory�for eolltorm b P >t the well wateranab►ata,
lndieates that tbs well b free from poundon from that[aeterfa and a pre a es of a compounds
nitrogen and nitrate nitrogen b equal to or less than S pan,p and the that n other ammonia
are triggered.A�,of the anaiyds mast be attached room'provided that ne other taft"aiterfa
�( fhb form.]
1 O(Ye described oo) e!gym fall&I have determined that one or mM of the
m 310 CM R 1 S.303, therefore the system&&The s above ner should criteria exist m
Health to determine what will be necessary to correct the ihilrar��m owner should contact the Board of
E. Large Systems:
To be considered a large system the system must s
BPd� erve a facility with a design flow of 10,000 gpd to 13,000
You must iadi either`yes"or"no"to each of the following;
(The following cri . apply to large systems in addition to the criteria above)
yes no
— — the system is within 4 t of a surface drinking water supply
_ — the system is within 200 feet of a to to a
' 8 water supply
— — the system is located in a nitrogen seas' . e area
Zone Q ofa public water suppl Wellhead Protection Area—IWpA)or a mapped
If you have answered"yes"to question in Section E the system is considered a
"yes f is Section D abov large system has failed.The owner or operator of an large scoot threat or answered
significant threat r Section E or failed under Section D shall u yy �COU�!d�
ered a
i 5.304.The s m owner should contact the appropriate regional office of the Dim incorh 310 CMR Department.
Ti�l� Inonnnfin" Rnrn,4/1<11nnn 4
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CRECIMIST
Property Address: ZCt% L l"G.�S
Owner. Tf OrN r,Vxd e.
Date of Inspection:
Check if the following have been done.You it indicate "at"be as to each of the followin
Yes No
yl — Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the ptevions two weeks?
— Has the system received normal flows in the previous two week period?
— Have large vohrmes of water been kto&wed to the system recently or as part of this inspection?
— Wa+e as built plane of the system obtained and examined?(If trey were not available note as N/A)
1 — Was the facility or dwelling inspected for sign of sewage back up?
— Was the site inspected for sign ofbreak 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 of the bail les or tees,material of construction,dimension deptb of�4 depth of sludip th of scum?��
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurthce sewage disposal systems?
The size Bad locadon of the Solt Absorption System(SAS)on the site has been determined based on:
Y7 no
Existing information.For example,a plan at the Board of Health.
J— _ Determined in the field(if any of the failure criteria related to part C is at issue approximation is unacceptable)[310 CMR 15.302(3)(b)) PP boa of distance
Ti►1� C inon�iNin" V—,"rul 4cjinn 1 S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: co,D h
Owner.
Date of Ins*tfou: p
RZSIDENTIAL FLOW CONDITIONS
Number of bedrooms(design):3 Number of bedrooms(actual): ._J
DMION Sow based an 310 C%9_t13.203(for example: 110 gpd x#of bedrooms):
Number of co:rent feeidenos: -Za-0
Dow rssidence have a garbsge grinder(yes or no):Yn=6
Is laundry on a aepsrate sewage system(Yea or no):YM[if Yes separate inspection reWfred)
Laundry"d=ioepected(yea or no).�
seasonal use:(yea or no).-)Lb
Water meter readings,if available(last 2 years usage(gpd)):
:zkrn
Lad dab ofoc�or )
cupaacy.Ma2—
COBSUMCIALANDUSTRIAL,
Type of esteldisihnalt
Design flow 310 CMR 15.203): and
Bade of design Sow( agttetc.):
Grew&V preset(yes or no):
i Industrial waste holding tank present(Yea or no ._
Non-sanitary waste discharged to the Title S sya ar(yes or no
Water meter readings,if available• '—
Last date of occupancyAme:
OTHER(describe
Pumping Records GENERAL UOURMATION
Source of informstion: u.S r1C—Y,—
Was system pumped as part of the inspection(yes or no): t-�0
If yea,volume pumped:_gain—How was quantity punsped determined?
Reason for pumping:
TYPE OF SYSTEM
�J Septic tads,distribution box,soil absorption system
Single cesspool
_Overflow cesspool
—Privy
—Shared system(Yes or no)(if yes,attach previous inspection records,if any)
_InaovatiWAltemstive technology.Attach a copy of the current operation and
obtained maintenance contract(to be
from system owner)
_.Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all cornponegb,'date installed wn)and so,1}rce of information:
Were sewage odors detected when arriving at the site(yes or no):
i
Ti►In C Tncruolinn 1+'nnw 4/1 Vlnnn tt
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address L ' �S
Owner:, ,
Date of Inspection: O
WELDING SEWIR(locate on site plan)
Depth below Materials of caograde: c�r w
st<ucttan:zLcUt irm �40 PVC_other(explain):
Dlstame fkom private water supply weU or suction line: �-�uJ►'\
Cow(on condition of joints,venting,evidence of leainge, ):
SEPTIC TANKS_(locate on site plan)
Depth below grade:
Material of construction:itconcrete_metal_sesglass--polyethylene
other(CTh&)
if talk is mew Ustego:( Is age confirmed by a Certificate of ComPliance(yp or no):_(attach a copy of
Sludge depth: _ ,
Distance nOm tap of a ge bottom of outlet tee or baffle:Scum thicknem: _
11
Distame fi�om of scum to top f outlet tee or baffle:
Distance from bottom of scum to bottom of qudot t e or baffle.��"
How were dimensions determined; 0
Cow(on pumping•ewmmead.aone,inlet and outlet
as related to`M (\ 1 go etc.): tee or baffle condition,structural integrity,liquid levels
Glr\() cc) ems,
GREASE TRAP:_(locate on site plan)
Depth w grade; _
Material of co lion:_concrete_metal_fiberglass
(explain): _polyethylene_other
Dimensions:
Scum thicto�ess:
Distance from top of scum to top of ou a or baffle:
Distance from bottom of scum to bottom of ou
Date of last pumping:
Comments(on pumping Wcommenda ,Inlet and outlet tee o e condition,structural
as related to outlet invert,evi of leakage,etc.): integrity,Liquid levels
T;Aw C Tnonsrtinn Ruin 4j1C/innn 7
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: lcl. A_ L6 Ovs
Owner.
Date of Inspections
TIGHT or HOLDING TANK: (tank must be pumped at time of Wspecdonxlocate on silo plan)
Depth belo
INsterial of concrete metal fiberglass_polyethylene other(exp� .
Dimensions:
aal!o:=
Design mow: sxllooa/day
Alarm present(yes ae no):
ALrm level: order(yes of no):
Date of he
candition of alarm and float switches,etc.):
/ DISTRIBUTION BOX: (ifpresent most be openedxlocate 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
1 Dge into of out of bo,etc
k4pj ):
PUMP CHAMBER (locate on site plan)
�s T wor or no):
Alarms in working order(yes o
Comments(note condition of pump c ,co
s appurtenances,etc.):
T410 4fnannrtinw pnrrn/G/1 S/1!1!1!1 8
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(co
Property►Address:2 - ( ,u S
e�1}��r =
Owner. ^ems
Date of Inspeetloa: 0
SOLI.ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
1eac6log_leaching dwnba%number: i—
lea.number:
leaching trenches,anmber,length;
leaching fields.number,dimensions:
overfiow cesspool,number:
ioaovatiWaltumative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic famkn%Level of
condition of vegetation,
0, 1 � �of\ J� S
i�✓� er ey-r-V^c e
CESSPOOLS: (cesspool must be pumped as part of lospectionxlocate on site plan)
NuMb and configuration
Depth— f liquid to inlet invert:
Depth of solids
Depth of scum layer:
Dimensions of cesspook
Materials of construction:
Indication of groundwater inflow(yes or
Comments(note condition of soil,signs of hydra fail of ponding,condition of vegetation,etc.):
PRIVY: (locate on s' )
Materials of co lion:
Dui nmio
Depth solids:
Co nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
T41a 9/nannn►inn ro%rm A/1(/7nnn 9
Pap 10 of l l '
OFFICIAL UiSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM U47ORMATION(condmmd)
Property Addrat: C)� L�`4�S
Owner: ��
Date of bspecdoa:
SXZrCS OF SEWAGZ DISPOSAL SYSTEM
Provide a sketch of tba sewage disposal system ioclndmi ties to at least two Pamaaeat refe<m=landmsrb or
benchmarim Locate an wolfs within 100 feet.Locate wbere public water supply ehters the Wflft& .
f '
A PrCIL 13
� O�oserv� {►�n �o�
P- 3-- `ZO` l33 LAy
1A
I V
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propertp Address:2 L t,^ h S
1
Owner:
Dab of Inspecdon:�' f l 7
SITZ EXAM
Slope
Snr&ce water,
Cbwk ceUu
Shallow wells
Estimated depth to ground water_.lL:._feet
Please indicate(check)an a:ethoda used to determine the high grand water elevation:
Obtamd am system design plans on record•If check4 date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Cbeclmd with local Board of Health-oplain:
Checked with local excovatorso installers-(stbeh documentation)
Accessed USGS database-explain: l7 ZS Z ZQYee,C—
Y must describe how yo a fished the NO o d water elev don:
1 � 2 o ex-
r
s F}
T:►1a C Tnvnnotinn R^rm All lqi)nnn f f
s
/ " TOWN OF BARNSTABLE
LQ,"ATION U L^r(�,�P1'\ Li 1�-�S SEWAGE# "111
VILLAGE ASSESSOR'S MAP&PARCEL
1 8— NAME&PHONE NO. �0 0eAS Sew r�C.
SEPTIC TANK CAPACITY 1Q Q 0
LEACHING FACILITY:(type) 14 o 1-cp nr,I. (size) Zoo"if, , 2-
NO.OF BEDROOMS 3
OWNER TC7et-T\0, eS
PERMIT DATE: n ? ' 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 S f tC. r � 4&135
z
ACV--
1
a
' 4
No. Fee
r�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
7
01ppYication for Migool *pgtem Construction Permit
Application for a Permit to Construct( , )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. / Owner's Name,Address and Tel.No.
Assessor's Map/Parcel J Gt'Y Tom/+ J
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
el 5 5F �� ���2 �.✓ mac" Yi-2
/3
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations nsvXer when applicable)
14 � 4,e iA-2 Ai Jar
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu this Board of Healt /
Signe a Date b
Application Approved y i i Date
Application Disapproved for the following reason
Permit No. Date Issued
oNo. " Fee
i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:t` Yess
" PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for �Migpogaf *pgtem Congtruction Permit
Application for a Permit to Construct( )_Repair Grade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address o�Lot No. / Owner's Name,Address and TV1.
L�G'T• G�,, Ttlt� �1�- .4arP ,Uc=v
Assessor's Map/Parcel/
Installer's Name,Address,and Tel.No. Designer's Name,,Address and Tel.No.
/�2�/� �,�S i to �>�2� >=�✓ fir' %i=2
o f 7 � _s- /-3
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( ) ^*
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Ans er when applicable) _
1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued-b�this Board of Health.
i Signed ^` e Date h
Application Approved by OX 6 1 z Date
Application Disapproved for the following reasoner Y
Permit No. -.► Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
Abandoned I
at oZS T �LO '� ha e constructerd in ccordance
with the provis' ns of�Title 5 and the for Disposal System Construction Permit N ated ��bt1
Installer tM kw Designer )O tr ren P.-.,Qf '
41
The issuance oft 's�pc_p4in t sshval�l not be construed as a guarantee that the y to ill�,unaai& esigned.
Date V/�cy InspectorE�
No. "� `� --��y�p• -----------------------Fee �td./ .
��__ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migoml *pgtem Congtrurtion Permit
Permission is hereby granted to Construct( )Repair(U,pgrade( )Abandon( )
System located at 2 1c- ��iP�I 4 h
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: Constructio �mius he co leted within three years of the date of this pe
Date. ! Approved b
PP Y �
TOWN OF BARN$TABLE
LOCATION ®T SEWAGE#o10 Ole
'�
VII.,LAG T ASSESSOR'S MAP &.LOT
/ j
INSTALLER'S NAME&PHONE NO. � C{��✓S i �0 7 7,^ 3 6
SEPTIC TANK CAPACITY 10.4 c r rr
LEACHING FACILITY: (typej�''y''C.A� 5�V F"Area' -gsize)PX (l X C�_
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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 Feet
within 300 feet of leaching facility)
Furnished by
r
�jb�- '7o iooa
PG� / 7
I -� mP AddO
4r
4/
Town of Barnstable
f"E Regulatory Services
yP cos
Thomas F.Geiter,Director
snxxsTasLe.
HAMPublic Health Division
rEoe. Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 2W4
Designer: J � �� P14 Installer:
� Ar—ci4 Commvc-POA)
�� �
Address: . T°0 Address: \N C-_,S`Mfj Gb-tL16
5. 5AIJ0IN)" AAA 0 2,53 7 H-14A-NJJ)S A
On was issued a permit to install a
( to� (installer)
septic system at �� C f� 0 0_A I+S R O' based on a design drawn by
(address)
S,dated,
(designer)
1-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.
I certify that the septic system referenced above was installed with major hanges (i.e.
greater than 10' lateral relocatidn of the SAS or any vertical relocation of y component
of the septic system)but in accordance with State& egulations. an revision or
certified as-built by designer to follow. \N OF MgsSq
DA E
' o M cn ,1D�
/ (Insta /
ees Si afore) / 1 40 0 �1 V
FC+I s-V
SAIVITAR\P�
J
f ILIU4
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO. BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH-DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
TOWN OF BARNSTABLE
/ iGJ fb
LOCATION CJ�RT t A/ ,O SEWAGE #;Z40'9c
VI'LAGS C '✓7' 2 Y��r (� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ����{ �✓S? C® ?7-�� /� �.
SEPTIC TANK CAPACITY l®O y EX t s° i
LEACHING FACILITY: (type) y �`'`'C�? �✓F,/T2lo/blxsize)PL X / X r2.
NO.OF BEDROOMS
BuELDER OR OWNER
9
PERMTTDATE: e4ca 17C 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 wetlandsexist
within 300 feet of leaching facility) Feet
Furnished by
p o =6 r
TZi `23
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
FRECEIVED
JUN U 2 2004
TOWN OF BARNSTABLE
TITLE'5 HEALTH DEPT.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 298 Captain Liiah's Road
Centerville, MA 02632 FA��ED INSPECTI01�
Owner's Name: Estate of Rita Sullivan
Owner's Address: 79 Sunset Circle
Mashpee, MA 02649
Date of Inspection: May 20, 2004 9 r
WJAP
Name of Inspector: (Please Print) James M. Ford PARCEL '
Company Name: James M. Ford
Mailing Address: P.O.Box 49 LOT
Ostervft MA 02655-0049
Telephone Number: (508) 862-9400
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 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,I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system.
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
✓ Fails
Inspector's Signature: Date: May 22, 2004
The system inspector shall submL 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
' Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
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.
Answer yes,no or not determined(Y,N,ND) in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
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
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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level-in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
Yes (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
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:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
5
i
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 0
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 2 years ago-per owner
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 4111178-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 298 Captain biah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any igns of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
i
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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 was level. Solids were present. The D-box was broken down structurally and needs replacing.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
i
Page 9 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 298 Captain biah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'
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.):
The leach pit had 4'ofliguid on the bottom. Solids were present. The scum line was up to the inlet pipe The leach pit showed
signs of failure. The bottom to grade was 8'.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
A � B
I77 Q
a
3
y ys� 3s6
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 298 Captain Liiah's Road
Centerville, MA
Owner: Estate of Rita Sullivan
Date of Inspection: May 20, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using a Barnstable topographic map and water contours map, the maps were showing approximately 30'+/- to ground water
at this site.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
1]
,•,'�1 �"'' c„, rye um
.. AssEssoRs MAP : 3 TEST HOLE LOGS
7 ;; NOTES
PARCEL
,n 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
FLOOD ZONE : N rJ �1 k Z r2� 50 I L EVALUATOR : , Nei e.� 06
THIS PLAN,
�� i 1995BOARD OF HEALTH REGULATIONS. TOWN OF
WITNESS : OT-. ,�►I-�4�
REFERENCE : I2,1 (7 DATE : �JJUNE_ 1 1 SQQ+ 2 THE INSTALLER
." ) SHALL VERIFY THE LOCATION OF UTILITIES,
�
s M w�'4� �°` � t• � �� �7 � �NUS
PERCOLATION RATE : SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
O
INSTALLATION.
0 TH- I 4 TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
tE EL �, ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE
fie• -
DETERMINATION.
4 r
Lo
4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS
SPECIFIED OTHERWISE)
LOCATION MAP(0' S ►� L �S�� 1 ' rti 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
GARBAGE DISPOSAL.
q 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
3.y7'; 22-7 q4 A=-L7,So SAN MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON l
ABASE OF 6"OF CRUSHED STONE.
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SEPTIC SYSTEM _ �
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FLOW ESTIMATE
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l BEDROOMS AT GAL/DAY/BEDROOM - `�7jb GAL/DAY
SEPTIC TANK
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SIDE AREA: E�)2_�)LZ 0.7y
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DUXBURY, MA 2332
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DATE HEALTH AGENT (7.81) 585-0293
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