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Home My WebLink About0008 EBEN SMITH ROAD - Health 8 Eben SmithRoad,, Centerville'_ P A 171 '�153 00%ndef1wr 152113 ORA' 100/0 P2 I E` r Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: 0 key to move your J cursor-do not Mike Bisienere use the return key. Name of Inspector Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Citylrown State Zip Code 508-280-3356 S 13938 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 05/18/2013 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 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. ""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. rn p/7 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�' 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 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): l5ins-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 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•�' 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. City/Town 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 Y P P Y (SAS) 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11110 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.803, 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 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): '220 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is Centerville Ma. 02632 05/18/2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ,•�' 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 16" 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: 12"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: standard 1000 gallon Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 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 38" 1" Scum thickness < Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? field instruments 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 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: gauons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •'" 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�' 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: two ❑ 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 Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 2 A _ ; 31 , ,,\,e�' J) - 3 - 1_/6 0 oC 1400 s c _ A E21 � y O t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �h 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 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: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I aguared a hole at a lower elevation and shot elevations with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Eben Smith Property Address Phillip Ford Owner Owner's Name information is required for every Centerville Ma. 02632 05/18/2013 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 J�. �. Leac�►�°�q PIT 7a 1 C 6rovt')<-A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF-B}�A�RNSTABLE LOCATION SM�"` SEWAGE # VILLAGE f-rVi ASSESSOR'S MAP & LOT -7I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a LEACHING FACIL=: (type) CoX�0' (size) 1000 NO OF BEDROOMS cL BUILDER OR OWNER s81+41AMA C Ck 1 PERMITDATE: 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 �r1 S/ eyon -T. r0/ ,a a p Q a 3a 3 3G 3y y y( as a(o S� i { Ra COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS M. -, DEPARTMENT OF ENVIRONMENTAL PROTe�T101l; aw _ r- cr3 M.TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 8 Eben Smith Road Centerville. MA 02632 ICR IS 3 Owner's Name: John Saltalamacchia Owner's Address: Same Date of Inspection: February 10, 2005 Name of Inspector:(Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,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 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Furt r Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: February 11, 2005. .The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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: 8 Eben Smith Road Centerville, MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Eben Smith Road Centerville MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same 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: 8 Eben Smith Road Centerville, MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same 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 ''/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.] No (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 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 Eben Smith Road Centerville, MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same 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)J. i i i I I i 5 i I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 8 Eben Smith Road Centerville. MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No 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)): _2003-29.000 gals.:2004-26 000 als Sump Pump(yes or no): No Last date of occupancy: Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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 on 5/03-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: Approximately 1980-second pit was added on 1118188 per as-built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Eben Smith Road Centerville. MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same 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 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10" 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 signs 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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Eben Smith Road Centerville, MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same 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. The liquid level was normal 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 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Eben Smith Road Centerville, MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: _ 2-6'x 6'(1000 gal.) 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 both leach nits had approximately P ofliauid on bottom The scum line was approximately 4'up from the bottom There did not appear to be any signs offailure. 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 11 OFFICIAL INSPECTION FORM-NOT TOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 8 Eben Smith Road Centerville, MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including fies tnqt least two permanent reference]a-dmarks n benchmarks. Locate 1 wells within 100 feet. Locate where public water supply enters the building. ,Q a p Q a� sa y 3 3� 3y y y� as a(,0 s(o 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: 8 Eben Smith Road Centerville, MA 02632 Owner's Name: John Saltalamacchia Owner's Address: Same SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- 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 Barnstable topographic and water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed 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. 11 CERTIFIED SEPTIC SYSTEM REPORT P 00 LOCATION 82Al�j�� i 8 EBEN SMITH ROAD , gig CENTERVILLE, MA 02632 MAP 171 PARCEL 153 LOT 293 PREPARED FOR BELLE R MR. & MRS. DAVID W . SALOMAKI 8 EBEN SMITH RD CENTERVILLE, MA 026.32 BUYER MR. & MRS . JOHN F . SALTALAMACCHIA 26 CONGREVE ST . ROSLINDALE, MA 02131 PREPARED BY HILLIARD HILLER, JR. P.O. BOX 250 CENTERVILLE, MA 02632 508-778-1472 ..' Commonwealth of Massachusetts Executive Office of Environmental Affairs_ Department of Environmental Protection Wltllam F.Weld Gowmor Trudy Coxe s.c,.tary.Eoen David B.Struhs Oommlubner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �Property Address: $ v 6 ITN Ld�I��viCc A41dress of Owner: Date of Inspection: /o/a 314ts Of differenO Name of Inspector: H/G[1^e p N/G[41( Company Name, Address and Telephone Number: . ,eO ,dv)r op_S-,_5 G �.dllC/Lsi/ALL � �l3 v�Gj2 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 4--lasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: Aj SYSTEM PASSES: 6/ 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES:. One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) ,, 1 One Writer Street a Boston,Massachusetts 02108 a FAX(617)556.1049 a Telephone(617)292-5500 i�"j Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) - Property Address: 8 646,A/ Owner: ^*I 4flv/o Date of Inspection: B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feel to a surface water supply of iribulary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria 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• D] SYSTEM FAILS: I have determined that the_system violates one or more of the'following failure criteria as defined in 310 CMR 15.303. The basis for this.determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: B cS/�j 11/f Xo G�t•vTk�v/GG.� Owner: A7"e' dam(//O !.4/ Date of Inspection: �p�aj/ysi D]SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: $ 164CAI SM>Tly R G�',�/l !/1L4'ot A,-,A)p Owner: Af4- &Iexlo 5/9L�sA�; Date of Inspection: Check if the following have been done: _(e-Pumping information was requested of the owner, occupant, and Board of Health. VNone of the system components have been pumped for at least two weeks and the system has been receiving norn ial flow rates during that period. Large volumes of water have not been introduced into the system recently or a5 part of this inspection. ✓'As built plans have been obtained and examined. Note if they are not available with N/A. _/The facility or dwelling was inspected for signs of sewage back-up. ✓the system does not receive non-sanitary or industrial waste flow _jL'The site was inspected for signs of breakout. ✓All system components, eluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Ahe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. l/ The facility ov ner (and occupants, if different frog^ owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 33COO' gallons .Number of bedrooms: oZ• Number of current residents: 0Z Garbage grinder(yes or no):_V Laundry connected to system (yes or no):y Seasonal use (yes or no):—A9 Water meter readings, if available: J/ S3_a:'"o G/9 L /yq 3 Last date of occupancy: LI 94A,7G y COMMERCIAUI NDUSTRI AL: Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING E ORDS and source of information: 8P9 f O it /v e/W 144 0/114/ G�a3�� a a/ys �°�t cr.✓,r '� System pumped as part of inspection: (yes or no).A&V If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM J_ 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) Other(explain) APPROXIMATE AGE of all components, date installed (if knownl1 and source of information: VPit4/04-,t! IdIT Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ff �'�G'� ` >1i� R� G1�•vT �'GG,[ ,�e,� Owner: 11l iP. D/l d/D G./ SAL,�O* Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete_metal _FRP—other(explain) Dimensions: Sludge depth:16— r� Distance from top of sludge to bottom of outlet tee or baffle: o?8 Scum thickness: O / y Distance from top of scum to top of outlet tee or baffle: 9/. Distance from bottom of scum to bottom of outlet tee or baffle: �� Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 74A,9t Ae-V T I__5 L yn-1 40 GeiziQ GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of <rurn t- bottom of outlet tee or bathe: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION.(continuecO . Property Address: 8 8�� :5-oV/l// /Q�. CX!/f.C-fv/�G.[ Owner: /yliQ. �19d/D G✓ wi LD�z i�/."�" Date of Inspection: /vla3�9> TIGHT OR HOLDING TANK:_ " (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP other(explain) Dimensions: Capacity: Qallons Design flow: rtallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:-I (locate on site plan) Depth of liquid level above outlet invert— Comments: o � (note if level and distribution, is cqu--!, ev;clence of so!id� carryover, evidence of leakage into or out of box, etc.) dOJt Lv�kr� D. /�vL,CTS GvT tytwZ— czdlIL its S/c,v _ L�A.`lJGF PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 t� $�'r►!l/��O G .�T v/�-G2 /sJr/� Owner: Atoof. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):v (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 0Z. leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) A'd> .S!C.d/ f-e14eellr 0"/1 ,f- 5; �iTis/ c��ts G 90 Frill /PAD /o/TImpGi/? f LS77^o �vL( CESSPOOLS: _— (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) B SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued} Property Address: -71Y ew LG iL A ff Owner: 18j,,f. 41f 4o'lO G✓. S/fGo^e/ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: , include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' oe 1 o PoRc.4 I - s? � car.•3•� DEPTH TO GROUNDWATER Depth to groundwater: /P. feet method of determination or approximation: MX,6. 5r,-?V4d G/S S/?Z EGBz�/1rdel / .Qe .57: 7/fE som(/s1?�/�L,2 O%36zit n l✓r91.1it i^r3l�G.0 /v�i1= .�34.2 !J/lAt,�/� 6,o% , -S Til d Cr/l U%yDlrA?X/I Tca itE /9T �i 1 X vi9T,�.+� 3S� 710 , vS GS U>RQl?cfio.v /S �_ (revised 8/15/95) 9 i%LIZ No —_ C> FEB $.....2.f]...Q.Q THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..................Town............0 F......B.cl.r.IAS t.a-ia� .................................................... Appliratilazt for Dispoii al Workii Towitrurtion Frrvad Application is hereby made for a Permit to Construct ( ) or Repair (gX) an Individual Sewage Disposal System at 8 Eben Smith Road Centerville ................_........_............ ........................................................ ................------...._.._.......-------------•- :----...-----•----------•-......-----•-•-•-- Location-Address or Lot No. ...................................................... ...---.......----•-........------•--------............---------------.......-------•-------------- Owner Address a J .P.Macomber• ............ ----•--- ..- --•------- Installer Address QType of Building Size Lot............................Sq. feet U Dwelling X-No. of Bedrooms..........a...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.........---.--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------------ •--------- --------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit..............---... Depth to ground water-.-.---------._._------- (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------. Depth to ground water................... -------------------------------- --•-------•-----•-•----•--•---••----------.._.......---------_.............................................................. 0 Description of Soil....................................................................................................-----------------------------------------------------------------•- x Sand & Gravel U ------------------------------------------------------------------------•-----•------------------•-------------------------------------------....--...--...........................-•--............. W UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------1-.1D.0.0...ga1Lon....pit.............................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1 i i I - 5 of the State Sanitary Code—T hejqndersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued y e and of he ned-- ----- -------- -----,----------- ApplicationApproved ........--..... ----. .............................................................. ----- ................... Date Application Disapproved for the following reasons----------------------------------------•--------------------•-------------------------------------._......_...-- .................................•-----•-------------••--•--••--•--------------•---.....------------•----------------------•--•-•----------•----••------•--•------------- ft6h.., Permit No. ..........�- o Issued.......�.1. - � , Dsu i N. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----------------..Town............OF.......Bar:.>w-l;.a 1:a----------------- ------------------- Appliration for Disposal Works Tunstrnrtiun runtit Application is hereby made for a Permit to Construct ( ). or Repair kX) an Individual Sewage Disposal System at: Smith Road Gei:terville Location-Address or Lot 1o. Iad=+l=1 5 3.;�:ilay.i._ -----------------------------•---•-------------- Owner Address .....J._.P..MaC.Ol31,UaS:.--•-•......-•-------•------•------------•-------------•... ...-•---•......----•-•-•---•----•--•---.......-•••----•----------••---•--------•-•...........--•-- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling-T No. of Bedrooms...........3...............................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons............................ Showers YP g ---------------------------- P ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------•-••••--•-•----••--••••-----•-•------------•-•................................................ Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity..........._gallons Length................ Width................ Diameter---------------- Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_------------------ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------------------------- ,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •---•-•-••-•-•--••--•--•--••••----•---••--•-••-•-••-••-•-••••--•----•-•.....................••-•••••......................................•------------------ 0 Description of Soil...................................................................................................................................................................... x Sand. & Gravel V •--••-••-•-••-••---•-•-•-••-•-•-•••••......••••-•-•---•---•-••••------•--•---••-••••------------•-••---•-•••••-----••-••----•-•-------•-••-•------•-••-••-••-•---------•••-•••----------•-•-••---....... W VNature of Repairs or Alterations—Answer when applicable................................................................................................ •----------------------------------•---------------------------------------------------•--------------------•-----------...I-1.000..-g-a.1.1011.--ru-t------------.............---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued,by the board of health. ' //- I- Date Application Approved BY •-----....... ---•-•----------------•-------•----------------9.. Date Application Disapproved for the following reasons:................................................................................................................ ....................................... -----f- Date PermitNo......................................................... Issued....................................................... D_t�_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Trrtifiratr of Tnntpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X.� by........... ...--•---.....•--•-••------------------•-•...----•-•-----••••-------------------•••--------•---...._...........••-----•-------•••••---.....------•--•-- Installer at............R...Eb.en...S.mith...Rc�?d-_-Cekite•�-vi I le • -••••---•--•--•••-----•••-----•••----•---•----••••----••---•.....••-••••-•------•-•---...._••••••--------- has been installed in accordance with the provisions of 197 ice- 5 o �,, fate Sanitary Cgde jsj c soil d in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. \ DATE.................................ft -1. �.16/....................... Inspector....................... ..1.10............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable C�E OF..................: n NO......................... FEE.....d... �.0.l1 Disposal Works TDOnstrurtion Uprrutit Permission is hereby granted J._...Mac�m>�_�r----••-----•......--••••......••••........................................................ to Construct ( ) or Repair an Individual Sewage Disposal System at No............8-.E:en..Smith Road Centerville --- r ;.�......•------------- Street 1. �(? /1 I 1 l as shown on the application for Disposal Works Construction Permit No.-.-• -='' ..... IPat ........... Board of Health DATE....... -----•--•--••-•-••-••----•••-••-•--•••--••......••------•---..--•--- r FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ! r , b TOWN O;;F�� BARNSTABLE LOCATION � {y,i7 l/ —_._-.__ SEWAGH # ASSESSOR'S MAP cra LOT -- JG INSTALLER'S NAME & PHONE NO.3, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC PLATER_ BUILDER OR OWNER DATE PERMIT ISSUT'D:_ DATE COMPLIANCE ISSUED;_��_ VARIANCE GRANTED: Yes No -----�� c , �' TOWN OF BARNSTABLE LOCATION F3 46LAI 5,*I- fl lea SEWAGE # -moo vTtLAGE ASSESSOR'S MAP &, LOT 121115.E INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /d�TS �dJ (size) .NO.OF BEDROOMS R OR OWNER mile ,d7f//D 4" PERMTTDATE: //- /-88 COMPLIANCE DATE: Separation Distance Between the: ✓0� 1!«S� Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 44 7�� 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 facili ) Feet Furnished by I ;a7�G k by UGSi� i I Pal&N VS 3 P/ L 0 CAT 10 N 1�,,,, zel�— S`E W E P E R M I T N 0. ,Lot 293 -'"i„^a v;„gk „ na . 80 184 WiLLAGE Centerville MA. I N S T A LLER'S NAME A AD PRESS Alfred Fuller Cotuit Rd, Marstons Mills, MA. • f UIL0ER OR OWNER Alan E. Small, Inc. Box 536 Centerville, MA. DATE PERMIT ISSUED DATE COMPLIANCE ISSUED e�� \ L w � \� .,4pa v M ' THE COMMONWEALTH OF MASSACHUSETTS BOAR® O HBA TH ...............OF......... -.. .-.-....... - ApplirFation for Diipnial Work,5 Tonarurtinn thrmit Application is hereby made for. a Permit to Construct ( ) or Repair ( ) an IInndividual Sewage Disposal System at: - � '� ...... . .. _............... .•---.._...--• T_......... Location- ess �'�' or Lot ..._ ..•••. -•-- •-•......._•• ............. ••••--•••------ . .. ---- -- ... .. rLedress W Installer Address d Type of Build ng Size Lot �_Sq. feet Dwelling—No. of Bedrooms............................________________Expansion Attic ( ) Gafbage Grinder pi Other—Type of Building ____________________________ No. of persons............................ Showe ( ) — Cafeteria ( ) Q+ Other fixtures •-•-•------------ ------•..--------------___._ 12_ •---- ------------- Desi n Flow_.__.___' ._ ___ allons per person per day. Total daily flow_-__._ _. __ W g - •--iJ-CS---- --g P P P Y• Y - - -- - ------------------gallon. WSeptic Tank V Liquid apacity_/gallons Length................ Width................ Diameter---------------- Depth................. Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../---------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing n `" ---- Date a Percolation Test Results Performed Y. _.r�1?.?t/f_.____.__. _"_____7 ._.._-. ,4 Test Pit No. I................minutes per inch Dept of Test Pit____________________ Depth to ground water____________________.__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -- ....................1l---------- ---------- --- Description of Soil----- ---V............. - -----•---- W •--•-•-•-•-•------------------------------•-•--••-----••-•-•------..---.---------------•-••----...•-------------•---------------.._.___._------..._.----•••---•-••---•-..._.._.___---•---------•--___._. VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ---------------------------------------=---------------------------•-----•------------........_..___._._-------•-----------------_______._..__.•--..__._...__.._..___------.__-------------•---._...---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T` � p 5 of the State Sanitary Code— The undersigned f rtl:er agrees not to place the system in operation until a Certificate of Compliance has been ' u by the� of alth. --- ---- ------------------•------------- Date Application_Approved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:................................................................................................................ Date PermitNo......................................................... Issued f>r�.... .......----...---•................ Date ..... Fmu................. ......... THE"COMMONWEALTH OF VASSACHUSETTS t BOARD O H BA T .............OF..... Appliration for Dhipugal Workii Tomitratrtion Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Selvage Disposal System at: I .. ........................... 1-2r..........wLocation ••ess ......--------------------°L Lot ___.. rer Address a •-----••---•--- r ----^ ---• •--... ----•-.....-......-•-••----.... ............................................-.......... -•-- + .......----- Installer Address Type of Buildi g Size Lot � �.Sq. feet Dwelling—No. of Bedrooms.._.. ..•.................Expansion Attic ( ) Gafbage Grinder Other—Type of Building ............................ No. of persons............................ Shok_ _` ) — Cafeteria ( ) Other fixtures - ��. -- -•--•- -•_..._. ............. _Design Flow ..gallons per person per day. Total daily flow_______ > ...............gallons. WSeptic Tank L>quid apacity./,#'Ilgallons Length________________ Width_.:......._.__._ Diameter..._.__...__:_ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_ ':'._.._..._._...sq. ft. Seepage Pit No.___-•-_I.._____-_ Diameter.................... Depth below irilet........_......::::_•Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing ( ... f r> Z 2 Percolation Test Results Performed by'._ _ _ __..-.__ s1-.._....___.. Date..___.��...._.... ........ a Test Pit No.'l................minutes-per inch Dept] of Test Pit.................... Depth to ground water------ ................. 44 Test Pit No. 2........:•__;.__._minutes per inch Depth of Test Pit.................... Depth to ground water....................... �j --- t �i n.......-----•-- .... . D Description of Soil...... . . ... .. ...... / -• - s -- - Ur =� ---------------------------••-----••----••---••---- W UNature of Repairs or Alterations-7--Answer when applicable-----------------------------------------------------_.......................................... ------------------------------------------------------•---•--•--__---- Agreement The undersigned agrees to install the aforedescribed Individual Sewag Disposal System in accordance with the provisions of:T`T I p 5 of-the State Sanitary Code— The undersigned f -t]er agrees not to place the system in operation until a Certificate of Compliance has been by the of alth. Signed,_ ...................� - .. .. ... ..". Date ApplicationApproved BY...................................................................................................- Date Application Disapproved for the following reasons:---•--•-----•-•---••--•----••-----------••------....--•---•--------------------•----•--....--••---•------...._ .................................•-•----...--•--•----•--•---••----•---•--....-•••------•-••...-•---••••-•--•-•••--•••------------•-•----•---•------..........................=......................... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA T .......... ...t. ..............oF..... .. . 1: . Trrtifirtt#.r of Tantpliattrr THIS I TO fFY, That the Individual Sewage Dispos System constructed ( �r epaired ( ) by .. " =-------------•-.... ----------• --••---------••--------••. ti J! :_ at has been installed in accordance with,tle provisions of TO, 5 of Th State Sanitary Code, as descri din the application for Disposal,Works Construction Permit No._'_.. _.._. dated-------- ........................... THE ISSUANCE,OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM'WILL FUNCTION SATISFACTORY.Y" , �d_(CDATE:...--- ------- ..................................... Inspector. -•-----•--•...................................................... TH-E''.;COMMONWEALTH OF MASSACHUSETTS BOARD O HEA H ....... ... / � NO.......;✓�:�...... FEE.. .................. :• � P. tl k tr uan rratit Permission erebypranted to Constr ict o eair ( ) an Indiv 1 Sew e sly em at ! :e � . ........ St,reet as shown on the application for Disposal Works Construction Pe,mi No......../ -'---- Dated.---- ..............' Ir................. �j✓. �:J i+ _} Board of Health DATE.......... ...................................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - R 5 �tS\TA - t.�o U Ste- l 0 OCs 6 A I_. l pI5PO54.L PIT - USE loco GDt_ . �I� � '`'"d� «�•��O 1 UPwail_ AV-EA = tSo s.t=. N so sue. A t .o _ So S.P.V. �- o o TOTAL 'fl eS,16 l = 4ZS [U ToTA t_ U cLt L�f FLow = 330 6.PD. 0 35 �EfZGDLDT1O�.1 tZl�TE i" iu o12 LESS. d � 12, IN) (� SMITA t'. Top 1=Na c too.m Loaw4 -d Poe loco IWV A 4'pP6 VKT 1w. GAL. RL,B Z f -Box R(,•G se nc _ tuv To W W. loon 9�.� ;•+v, tuv. L%Ac A A Pt T /.Z.A WASWED v STONt=. -{O.D CEZTtFIEID pLbT PL. 4t,1 LOGATI O" CEQT W-U I L-L9 - �b 1 IZ ►.�o SGAL�— �CALC— �t� c�-C7 bA''T- 5/3lISO I G G tZ T I t=`{ T;-4 A T T P G �Ql>ATI OO 5 taow u Pt_4 t.! R E t=i= Ea t.i L %4Z.Qj=-niJ W ITt-i Ttl` StD� LI►-�E: -� '�1 A►.lta SE- rLllAC1C 67 GQUIQGAA&."Ty OF T1aC: / _ I ` -To W I.J OC= �?f� .1J�iT-�+t 1. `� krle't�lLl. 1` 1 G 1 ems+ W;>5 r� f UA T G ��I c� ��` .�,,� �.r,...i'..�Gt + .� u��c� .: .�.. B/�XT E�Z S;. u�!� I•.1 G_ 1'1�IS C7LA►-1 1'S LJOT 2A6EL7 V4 AN OSTE��/1L�G c� /1iCASS• Ti1rr UFc Cam. S1IGWLD ANc�Li GAt-JT (NCiA-,lr VIC, U: ,c,