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HomeMy WebLinkAbout0159 GREEN DUNES DRIVE - Health 159 GREEN DUNES DRIVE, CENTERVILL A 4 i uu UPC 12534 No.2_153L_O,FT HASTINGS. MN TOWN OF BARNSTABLE LOCATION G ran by/US SEWAGE# VILLAGE ASS SSOR'S MAP&PARCEL INSTALLERS NAME&P ONE NO. SEPTIC TANK CAPACITY / 5,60 n LEACHING FACILITY.(type) PIT (size) NO.OF BEDROOMS OWNER e �/ PERMIT DATE: 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-rA-VP e,Cr) J . 1'd�� 3 0 , i Say ' � 3Sy CAS 3 � 1 �a . I ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ a i . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 159 Green Day es Drive Owner's Name: Tom Reilly -- Owner's Address: Date of Inspection: September 3. 2009 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: _ Q Q ✓ Passes ditionally Passes ee s Further Evaluation by the Local Approvi; Authority_. `*� ails ` Inspectors Signature: Date: Se tern er 11 200� �—I The system inspector shall subr'tapy of this inspection report to the Approving Authority( oard.of NeAlth ` DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow o01 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 only4escribes conditions_at th,e 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 I _ _ a Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 159 Green Dunes Drive Hyannis Port. MA Owner: Toni Reilly Date of Inspection: September 3, 2009 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 inuninent. 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: 159 Green Dunes Drive Hyannis Port, MA Owner: Tong Reilly Date of Inspection: September 3, 2009 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 aseptic 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 systein passes if the well dater analysis,performed at a DEP certified laboratory, for coliforn 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: . i 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 159 Green Dunes Drive Hyannis Port, MA Owner: Tom.Reilly Date of Inspection: September 3. 2009 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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 l 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 159 Green Dunes Drive Hvannis Port, MA Owner: Tom Reilly Date of Inspection: September 3, 2009 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 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 159 Green Dunes Drive Hyannis Port, M.4 Owner: Toni Reilly Date of Inspection: September 3, 2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): n/a 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: Currently 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 in 2008-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 on 3131180-per as built card - a pit was added on 713196 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 159 Green Dirnes Drive Hyannis Port, MA Owner: Tom Reillv Date of Inspection: September 3, 2009 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: 36" 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: 1500 gal. Sludge depth: 2" _ Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" . Distance fi-om 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.). Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakarze. The outlet cover is 15"below grade. 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 baffler 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: 159 Green Dunes Drive Hyannis Port, MA Owner: Torn Reilly Date of Inspection: September 3, 2009 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. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Continents(note condition of pump chamber,condition of pumps and appurtenances, etc.): i 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: 159 Green Dunes Drive Hyannis Port, MA Owner: Tom Reilly Date of Inspection: September 3, 2009 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'0000 goL) 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 neuter pit had 6"of water on the bottom. . The scum line was at the.same level. There did not appear to be any signs of failure. The bottom to grade was 7'. The cover was 6"below grade. 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: Coirunents(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): 9 J Page 10 of 11 - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 159 Green Dunes Drive Hyannis Port, MA Owner: Tom Reilly Date of Inspection: September 3, 2009 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. Fib nT i C qPA ' 3 S`l Cos N 10 e r Page I I of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 159 Green Dunes Drive Hyannis Port, MA Owner: Tom Reilly Date of Inspection: September 3, 2009 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- 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 snaps were showing approximately 20'to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been . inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will f action properly in the future. There have been no ivarranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system ia,hich have not been located and inspected. 11 TOWN OF BARNSTABLE �eo P-0 ��9 �v�Pp� ��rs /�rivv SEWAGE # VILI:'AGE ASSESSOR'S MAP &M INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J.foO LEACHING FACILITY: (type) s (size) --� NO.OF BEDROOMS ,�- BUILDER OR OWNER r PERMITDATE: S-1'1-166 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leac ng facilit Feet Furnished by �� o , �. /l Srh S�� � V 3 o v 777 3 y do- ry' �s ' i ASSESSORS MAP No;No. 911, FARCQNO: ,. 7 Fee k2o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS C 0(pplitation for Migaaf *psstem Construction Vermit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. 4,-t-0 3 Owner's Name,Address and Tel.No. S 9 �;.eoN �.yl✓s ,��,"v. Wst�F�/ �,ar�lrti Installer's Name,Address,and Tel.No. y g� Designer's Name,Address and Tel.No. J0-4..► I3 9a IrvN�-e , I c WGlnwr O . 7,-., 18 Type of Building: Dwelling No.of Bedrooms 3 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 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4o �A4C�,� zo .PAS 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 his oard of Health. Signed � Date 01—141-g0 Application.Approved by � .,.. ,......._ G—� Application Disapproved for the following reasons Permit No. !7/— Date Issued rpq k No. n a :/ 4 O ,f Fee `, THE COMMONWEALTH OF MASSACHUSETTS t7 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS w O orication for Migaal *p5tem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. a� �3 Owner's Name,Address and Tel.No. - - a., Warr Gortki� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �1$-gs9S` �OL+r AC, l}, Type of Building: Dwelling No.of Bedrooms' 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 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4101 o•c �a PX Gi'Pcf Date last inspected: •y 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 Mhi5 oard of Health. Signed Date Application Approved by Application Disapproved for the following reasons Permit No. 7Z — Date Issue THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed(- )or repaired/replaced,(-"')on ant 63 by 'T, �a�t� for /vy G► 1N Pur,.0s pr,vi /Yy as n s 4 '` has been const Wein c of Bancwith the provisions of Title 5 and the for Disposal System Construction Permit No ' �s. datedl " k� Use of this system is conditioned on compliance with the provisions set forth belo ( ' No. �S'' [� Fee ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Zi5po5af *p6tem Con5truction permit Permission is hereby granted;to— 170A.,, .tq �4 /7 to construct( )repair( Z-)an On-site Sewage System located at l-,ot 3 , Grt�•, a��s ���✓� # i-7� 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. All construction must be completed within two years of the date below. Date: �-aj L/ Approved by l� `t V 159 Green Dunes Drive Walter & Evelyn Gorski t 02647 Owners ca; � Subsurface Sewage Disposal ti Inspection Report Title 5 Town of west Hyannisport Hoard of Health Copy Service Pumping & Drain Co . , Inc. ( 617 ) 245-7576 P. O. Box 498 (800 ) 794-9265 Wakefield, Ma 01880 Fax ( 617 ) 245-7590 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 159 Green Dunes Dr . , W. Hyannisport , Ma 02647 Walter & Evelyn Gorski May, 28 , 1995 PART A CHECKLIST Check if the following have been done : XX Pumping information was requested of the owner , occupant , and Board of Health. XX None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. XX As built plans have been obtained and examined. Note if they are not available with N/A. XX The facility or dwelling was inspected for signs of sewage back-up. XX The site was inspected for signs of breakout . XX All system components , excluding the SAS , have been located on the site . XX 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. XX The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods . XX The facility owner (and occupants , if different from owner ) were provided with information on the proper maintenance of SSDS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms 2 number of current residents Y garbage grinder , yes or no Y laundry connected to system, yes or no Y seasonal use , yes or no If nonresidential , calculated flow: 110 gpd, total design = 548 gpd Water meter readings , if available : Occupied now seasonally Last date of occupancy GENERAL INFORMATION Pumping records and source of information : 9/20/93 per owner N System pumped as part of inspection , yes or no if yes , volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy N Shared system (yes or no) ( if yes , attach previous inspection records , if any) XX Other (explain) Septic tank with Seepage pit . Approximate age of all components . Date installed, if known. Source of information: 1980 per design plan N Sewage odors detected when arriving at the site , yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: Y ( locate on site plan) depth below grade : 1 ' to riser material of construction: Y concrete metal FRP other (explain) dimensions : 8 ' x 5 ' x 5 ' 4" sludge depth 3 ' 1" distance from top of sludge to bottom of outlet tee or baffle 1 2" 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 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, recommendations for repairs , etc . ) All appears satisfactory. 2 year cleaning interval recommended with garbage grinder . DISTRIBUTION BOX: Y ( locate on site plan) ND depth of liquid level above outlet invert Comments : (note if level and distribution is equal , evidence of solids carryover , evidence of leakage into or out of box , recommendation for repairs , etc. ) Under brick walkway, curb and paved driveway area. PUMP CHAMBER: N/A ( locate on site plan) pumps in working order , yes or no Comments : (note condition of pump chamber , condition of pumps and appurtenances , recommendations for maintenance or repairs , etc . ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : Y ( 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 and number 1 , 1000 gal . leaching chambers and number leaching galleries and 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, recommendations for maintenance or repairs , etc. ) Soil appears dry and clean 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, recommendations for maintenance or repairs , etc . ) PRIVY: ( locate on site plan) material of construction dimensions depth of solids Comments : (note condition of soil , signs of hydraulic failure , level of ponding, condition of vegetation, recommendations for maintenance or repairs , etc. ) i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM : include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' �roNt _ o � DEPTH TO GROUNDWATER: 14+ depth to groundwater method of determination or approximation: _ 1980 deep hole observation on design , data. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes , no , or not determined (Y, N, or ND) . Describe basis of determination in all instances . ( If "not determined" , explain why not ) N Backup of sewage into facility? N Discharge or ponding of effluent to the surface of the ground or surface waters? ND Static liquid level in the distribution box above outlet invert? N/A Liquid depth in cesspool <6" below invert or available volume < 1/2 day flow? N Required pumping 4 times or more in the last year? number of times pumped N Septic tank is metal ? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? N Is any portion of the SAS , cesspool or privy: below the high groundwater elevation? N within 50 feet of a surface water? N within 100 feet of a surface water supply or tributary to a surface water supply? N within a Zone I of a public well ? N within 50 feet of a bordering vegetated wetland or salt marsh ( cesspools and privies only, not the SAS) ? N within 50 feet of a private water supply well ? N 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. A ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Richard A. Mottolo Service Pumping & Drain Co . , Inc . 51AA New Salem Street P. 0. Box 498 Wakefield, MA 01880 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade , maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems . Check one : XX I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. gfz� z- Richard A. Mottolo June 5 , 1995 Original to system owner Copies to: Buyer ( if applicable) Approving authority L,oT 6 3 G26�N /�!//UES 06" LOCATION /.4-1-il7 WV "'t-tS E W A G E PERMIT NO. CUEST I• YA N 1y a Po R T- V I L L A G E Cj O/V f R .3 2 W/A N NO d S /. INSTA LLER'S NAME i ADDRESS 1W2 EM25 eZIAA-re w!!TL`wn on wN DATE PERMIT ISSUED � _./�2 _ �D DATE COMPLIANCE ISSUED zz3�/�v t 1 A 7 m (t9d No..---..--- � 9.7r Fl�>�...... ...................... --•---- THE COMMONWEALTH OF MASSACHUSETTS BOARD ) H A TH Application is hereby made for a Permit to Construct ( Y) eP-Rrepair-�— an Individual Sewage Disposal System at: / ozi s -- -------- ----------------------------------------------- Location.Address a or Lot No. &%ruiov �9'1�2,E' J.25 ..4!�i+4 ..........................��. 5/C/ nisi/r�B2S//?�. ?�G'' 0209®Owner Addre /�/wL--r----'- :'-G-----•--- -------------------•---------------------_.----- Installer f Address UType of Building Size Lot.,3fk.0 j3�.......Sq. feet ., Dwelling AeNo. of Bedrooms..-._.-&--------------------------------Expansion Attic ( ) Garbage Grinder (pf per, Other—Type of Building --------------------_-._-- No. of persons...------------------------- Showers ( ) — Cafeteria ( ) Q, Other fixtures ------------••---------------- W Design Flow..t�..Vt.....� .................gallons per person per day. Total daily flow4� y: ----...gallons. WSeptic Tank Le-'Liquid capacity/_500_.gallons Length................ Width.._---_-------- Diameter--------- ------ Depth--------- ------ Disposal Trench—No..................... Width---_--./.-_------ Total Length------ _------.�- Total leaching area--------------------sq. ft. Seepage Pit No........�.......... Diameter-------AO...... Depth below inle4.e -.... Total leaching area........----------sq. It. z Other Distribution box ( ) Dosing tank /fps,i'_ a Percolation Test Results Performed by-------------------------------------------------------------------------- Date------....--------------------------.--- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...._...-..-------..-..- Gi, Test Pit No. 2...............minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ -------------------------------------------------------------------------------------•-------------......................................................... 0 Description of Soil...O-Q?-`'ite. �jis Svf�----------- --/ i[:div.� ���� G �_6T G U lL ---- L�---------�-- '.-----...--��-•----•-•-•-•----•-••---•---------•----------•-----------------------•--•--•----------•--•---•-• .................................. ---------------------- ---------------------- ---•--------•---•------------------------------------------------------------------------------------------------------------ --------•----- UNature of Repairs or Alterations—Answer when applicable----------------..------------------------------------------------------- ...------_----------- ----------------------------------- --------------------------------------------.:........-------•--•---•----...--------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 o health. Signed ` -.�---••-------------------------- - `¢` 0 Date Application Approved B c- -. -- f ...�...--•--•-•--- -----..�..' ��.`--�-J.._ PP PP Y L f/ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- --•••----•---•------------------------------------------------------------------------------•------------••---•-----•------• -------------------------------------------------------------------------- Date PermitNo......................................................... Issued......................--................................ Date st u 4 L+` FaM�L.� • 3 � z Da,t L-*-( ;=L.ow II I Ica 'A a +501.=49,5r'..P.TJt SEP'RG TA-4%4 w 495 le2-00 90 7. uSE ISOO GAL• / .p G3 1 ">15Po,SAL Pt� y3E 34, 8 i L S UE1.vA�.L A GA SE x z.5 470 G.P:b- BOTOCA t 'Z 6 s, r- » � Per TM A2 78 x I-C, -78 G. P. D. .5'48t . P. v. 4 t=.A r= C, bA O L.'Y PEgco�T 1 ot.l PATc t I u 2 Mtt.t O(Z C. L' C � . . I tt• �,�' ` i oP F.1v = bo L•tc�t�s �G. 98` z�a' �,. ter:�..—'%t"�n �� ' ,; LL 4~ IWV. , _ pa �/ P,v� V15T tint [*AL. 9&.- -Z 6 8vx. 9�.9. Sc.IPt'iG itJt/. TUQ W. i LGA i ctao 45 8 I uv. 1w. •�: 6AL. 4G.D q("Z a' Lime" ;V SGb PIT �o ! WtT" TO w 66 Sy a or GR� z. 1 r.. �� Uzi �. CT T I Pt 9, Vt-oT pt_A N 4:�'IZO Fr L-F- AXIO►..1 \4 ES T H YA K,N 15 PO r-T W$T NO GALE;:: SGhL.t= I'`- 60 ' T�ATIc ��� / oU 1 cri cr,F,f T"AT Tt-1� FouN p�Tl o tJ 54�owU pL-a t�.1 ¢E�ESZE.t-tc6 F 1E¢.E.4>" GoMPL-`f S W I TI-t T41t-a. '=slL t..t I•at` L O-7` fo3 A►JD S Er"BAGK. REc?atiZ�M��►T�S OF I-We .TO"" tz tsr>a Q� ant.,o <,�evEyoe� T415 P�-0W IS UOT BASED oU AU ►tWWAAE.MT OfiT�=RVtt.Lb A�tA.ys. 5uevmt 4 T"G 0;=1=5GT; 'S"OULD UOT WF- USES To -Pe-TF-Zmi► C-- LOT L.IIJE.$. APPI.IGAt.tT AL.TE G©f�5 1 No.----__�........ Fins.... ....._.✓.......-_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .1..........o F..... .................................. . pplira$iun -fur Digpuiitt1 Works Tunitrnrttun Prrmil Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: / M: �`0 T '�� 3 LTi2CG-la/ 1�v/�L s /j��`'i t�i s /3'Z ___ ___________J_ ____..____.. Location-Address or t No --- ----------- O_w er Address Installer Address Q Type of Building Size Lot-M_t- ------Sq. feet V Dwelling-JZ-No. of Bedrooms__._-_rj----------------------------------Expansion Attic ( ) Garbage Grinder (1-} Other—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( ) Otherfix3 ures -----------•----•-------------------•-•----------- -------- ----------------------------•-- � Design Flow...........�S__________________________gallons per person per day. Total daily flow______.____ .___ ____j gallon.. W '' 77 `" 0 Septic Tank—Liquid capacity_____-.__--•gallons Length________________ Width..____....__._.. Diameter__..__.._..__.__ Depth___-______.._... W ' x Disposal Trench—No_____________________ Width-------------------- Total Length-------------------. Total leaching area--------------------sq. ft. Seepage Pit No........./--------- Diameter..../G........ Depth below inlet_._________.___ Total leaching areas_________sq. It. Z Other Distribution box ( ) Dosing tank ( ) i�JG- S•�= oPerclation Test Results Performed by...............•__..______-_ W ---------------------------------------------- Date------------------------------------- Test Pit No. 1________________tninutes per inch Depth of Test Pit.................... Depth to ground water.____________._______... f14 Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water__.___________________._ W -----4.....�------------------------------•---•------' D Q --- - - Description of Soil--------- ------_ - ------- p f 7 ------ - L- r V --------- --- ---- �- ------ ------------- -- - - W x --------------------------------------- ----- -----------------------------------------------------------------------------------------•-•-------------------------------- --------------------------- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------___________________________________________--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ArticI XI 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 t ' bo d health. �� Signed-1 Ile l-------------------------------------------------------------------- ---------- Date s Application Approved BY �, .�----------- `lli-:"... , Date Application Disapproved for the following reasons:---•---___-•------•----•------------------------•- -----------------•------------•---•-------•--•---------------- .. •. -•- --•• •••. ••-----------•••--------•-•••-------•-•--••-•--•-•-.__..._---------------------•---•----------------••---------•---------------------------------------- *', Date PermitNo......................................................... Igs"&d...................... .................................. Date THE COMMONWEALT'l OF MASSACHUSETTS. Eu BOARD OP', HEALTH Are l _ Ckrrtifirttte of Tuutphaurr ti P � TH154S TO CERT or R'cpaired FY, That the Individual Sewage Disposal ystem constructed ( ) ( ) L �3 c=L �Le �[ CZ by.......... // 7 -••••- ------------------ ••---••-----•-••-----••-•-----•----------•------- ". Installer ,/ / atlJ �`��- 1y1G- ----��l��,t/c= Z54f Z ......................`........................................................... has been installed in accordance with the provisions of A�r�-cc,�leX I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.�� l.-•----•-••--..-.-. dated_..._f___ _____________ PP P ----- �t!i-�---��: THE ISSUANCE OF'`-THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT ON SA, ISFACTORY. DATE-----------•-•-•-��- -• •-- � .......................... Inspecto z!' , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - © l>....................OF / i,?2iYST/ Lam: .......................... No.___-_Z.--•••--•• FEE--•t` �i��u�tti urk� Cnun��r�rtivat �ernti� Permissionis hereby granted................................................................................................................................................ to Construct ( 1,�or Repair ( ) an Individual Sewage Disposal System �z c L^/ 0v-5/�-S Z�•r Street as shown on the application for Disposal Works Construction�P it No ,.j_ �/}y___._, .- D/mated___. ......... -----------------• Board of Healthi�� DATE....../7--- � ` FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • -• C 7 6 3 G2 L o C`A I IO N L� � �',�Cy��✓iWev SEWAGE PERMIT N0. VILCkcL x . r /'>F. A Try ni", UC -f S INSTA LLEA'S NAME ADDRESS « n t W-U-I L D. -R opt c�wM it DATE . PERMIT ISSUED DAT E. CO .MPLIANCE ISSUED _ .Zz 4. J 3 Z_=44-ISO 4 _'N +rJ0 0. y 0AM 1500 GA,L_ �• wSA� PST v�fz 63 �ec�e,,,,au. Aezn t 16b �F �e G. P. D. TOTAL 1=�06t461.1 o �r too f=L OW4 9`t� Cs.P.A. Q i� a •° eA t- (� `p�1C rJ3�i r ` � I• i s j 7 sTop F&ro 9® r 7M' 1T ✓7) • .bo'. Q'AId w� /�C. 4.Peat Soo 1wv. �uw• 1-1.o ' .J F. _' TAU W.IV- LEACtJ Wi su 1,ls ivfGy " V,tJsC.VJ-,q f,�, �►? 89-84�d � z E C�2 T F•t o Pt-o-r PL A uC �QLEW Y/1+.t N+5 Po --AT--.._ .,.,�.y t'tiiAT ==�� GotitPc..YC 1ni�TM 'Tµ�• '�slbE�t�.e�, -T- �0 3 sad ®F 1A S` 0' 'C3 .. 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DATE: RRp 4 OR OWSSIONS N mE PROPOSED RENOVATION CHANGED OR COPIED IN ANYSiRUC"'TOEOERCI A"'tE MIFREI51-ITAT RESIDENCE ASSOCIATES FORM OR MANNER WHATSOEVERDRAWN W.NOR1Ny0E O[4CN AO_S_az_iAEAMC ioW' DISTINCTNE RESIDENTIAL&COMMERCIAL DESIGN WITHOUT FIRST ODTA)NINC THE Oi/04/11OEPMtb l ANDS&VECTOR 159 GREEN DUNES ROAD E%PRESS WRITTEN PERMISS ON N AND APNrovAL RECAROWC Ax101 MAIN STREET YARMOUTHPORT MA 02874 qND CONSENT OF NORTHSIDE CHECKED NsrnEPExaes N smucnma WEST HYANNISPORT, MA. IWO)362-2210 (90B)362-9602 DESIGN. r I r V DR rtp r X" II - I I @ I IA D o W 7� O a (n A N apD D' Gov m iE 3 afro �g m II Z I I �m II � I I M I I I i A m n Nm N m p r N I-1 II II II 11 II u D r r i N r rn 0 0 � rn y m rrr r A N N ^' m p mpap� ig aD ay mn�QAO V$ c�C ofI�qE ipm`Q�`�Oo�1Oml 2A ZIB 23ppyay NA �GA �mpg Nm0 p TNI aN 1g0 pNA =p1mNP11Qp� p 2212� hoomyy ma Aa Nip pt �ZZ� ZmZD m Dp�pD pD Om Or pniD� A� --113 CIO I �� ap3 =2: a n pp p G a OtlALE: 1 BN=1'-ON TAIE AND LOCAL RURDNG[ODES VMV TLY AamSS Da COUNTRY. DUE To COPYRIGHT DATE REVISIONS W EAT ARMY DSOL YARM&ES 5ua FIRST FLOOR PLAN 5 WEAMEB AND E CONDITIONS,SNL_ NORTHSIDE U1G WIEPoALS.ME RIP°595WT Of NORTHSIDE HEREBY EXPRESLY O 1 2 4 9 -4 E NVEETC..oB ct we 0 oN DESIGN ETC.. NOf1IN90E DEsGN DESIGN RESERVES IT$ COMMON LAW 5 NO RESPONSIBUTY OR UARg1TY COPYRIGHT. THESES PLANS ARE OB MY LOSSES ON DAMAGES"CURBED NOT TO BE REPRODUCED SHEET NO. DATE: uE TO ERRORS OR OMlsswNs N NE PROPOSED RENOVATION CHANGED OR COPIED IN ANY GR SDNCTURAL DMON''Wm ASSOCIATES DRAWN E DESGN.NDRMSDE DIMON ADVISES FREI SHTAT RESIDENCE FORM OR MANNER WHATSOEVER At IIEEORE CONNENOND CONSTRUCTION. WITHOUT FIRST OBTAINING THE J� • 1�04�11 ESE PLANS RE T"EN TO YDUB LOUL DISTINCTIVE RESIDENTIAL&COMMERCIAL DESIGN EXPRESS WRITTEN PERMISSION UNG DEPARTMENT MD/OR INSPECTOR 159 GREEN DUNES ROAD 141 ARAM STREET•YARMOUTHPORT•MA 02675 CHECKED OR REVIEW AND ARPROVAL REGARDING AN AND CONSENT OF NORTHSIDE DSCBEPENINES N SMUCNRAL WEST HYANNISPORT, MA. (50e)382-2210 (5oR)382-9802 DESIGN. _ I ——————— —————1 I I I I I I I I 1 I I 0 I I � I °r I i Iv I I I I .4 4_B• I I — I I iD D TILE WALLS —{ a A D m m r z p� vQ I s: OTILE WALLS Z TO BACK SPLASH �D I I r= m A mm rn N D �z A I o a —————————— I I I � I I I I I I I I I I I I I I I I —————————————————————J 1ATE AND LOCAL BIa1LXNG CODES VARY DALE: 1 8N=1—ON ATILT ACRoss T1rc cauN-Y. WE To o AND MANY OOQR vAmADLE1 sua COPYRIGHT DATE REVISIONS S NFAIIER AND K G4)SSMl, SECOND FLOOR PLAN NORTHSIDE Pro NATE/EAL4.ra MPDmREnY a NORTHSIDE HEREBY E%PRESLY 0 1 2 4 8 -sa MN. E aN Oa mxs�nmN RESERVES ITS COMMON LAW DESIGN MSiNL:1" "��'P' ETC.. NO n OR NE9tl1 DESIGN aESPR DANEYS I CURRED NOTMTOBE REPRODUCEDS ARE DSSCS OR DAMAGES UAMUNaaes Da OID5510M5 w iNE PROPOSED RENOVATION ASSOCIATESSHEET N0, DATE; CHANGED OR COPIED IN ANYsnsucnraK xnaENc¢s w DRAWN .NORIN9DE DE._ADVISES FREISI-�ITAT RESIDENCEFORM OR MANNER WHATSOEVER TE CO-ENCLNG CoIs7",,C NA WITHOUT FIRST OBTAINING THE NS BE TAKEN TO YONR LOCK DISTINCTIVE RESIDENTIAL&COMMERCIAL DESIGNEPAaraTAND/OR wsxc oa159 GREEN DUNES ROAD E%PRESS WRITTEN PERMISSION w AND APPROVK 11EGA_C ANY 1s1 MAIN STREET•YARMOUTHPORT•MA 02675 AND CONSENT OF NORTHSIDE CHECKED mScaEP, SwSTRucnRK WEST NYANNISPORT, MA. (50B)3E2-2210 150R)5Ba-RRO2 DESIGN,