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HomeMy WebLinkAbout0657 OLD STAGE ROAD - Health 657 OLD STAGE RD., CENTERVILLE A = I� $mom , , ad UPC 12534 ' No.21533LOR HAiTIN09.UN 4. TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE C- enif e r,y,Z/ g ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. 1;1ae�a,7 l C 7 —468, SEPTIC TANK CAPACITY /d o ;LEACHING FACILITY: (type) /d /�7,Q�T°O/LS (size) NO.OF BEDROOMS BUILDER OR OWNE PERMITDATE: COMPLIANCE DAM. f; 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 260 feet of leaching facility) Feet ` Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i s VQ '4 � w 413 i C0 'r A0-,,NF"`EUTH OF MASSACHUSETTS RECEIVED �j E ,,ECT-TTT'\,T OFFICE OF ENVTROi ivIEirTA].. ,4FF: RSAUG 15 2001 DEPARTMENT OF EN-V1ROilTMENTA.L PROTEC I1��N OF BARNSTABLE HEALTH DEPT. TITLE 5 O;FFICIAJ� INSPECTION FORM - NOT FOR VOLUNTARY ASSESSVIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR:tiI PART nn CERTIFICATION Property address: � ozU Uwner's dame: .Sle � - 0w•ner's address: � �z� (�11Q�j c oe d - Date of Inspection: Oame of Inspector: (please print)- tko'ui Cornpanr -Name: WIND RIVER ENVIR{)Ni►1TN� AL -- Nlailin'C' address: 561 MAIN STREET IIUDSON, MA. 01749 Telephone dumber: 1.-978-562.-4500 CERTIFICATION STATEI IENT I :en.i that I have personally inspccred the setivaae disposal system at this address and that the information reported oeiow is true, accurate and complete as of the time of the inspection. The inspection was pi-r:forrned based on my training and experience in the proper function and maintenance of on site sewage disposa:. s:srems. I am a D> P all.pr_ove.d system inspector pursuant to ' t ion 15.340 of Title 5 (310 C MR 15.000). The system::( Passes Conditionally Passes Needs Further Evaluation by the Local Approv inu authority Fails y +c��� Inspector's Signature: '`1_-_._._. Date: 7141-01 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) ,.within 30 days ofcompleting 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 sub4nit the report to the appropria-.:e regional office of the DEP. The original should be sent.to [he system owner and copies sent to the buyer, ifappli::able, and the approving authorirv. Notes and Comments x"-This report only describes conditions, at the time Of inspection and under the condkions of use at that time. This inspection does not address how the system will perform in the future andcr the same or different conditions of use. Pace '_ of I t OFFICIAL.., INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ( CERTIFICATION (continued) C Property Address: V V 1 49Z & ) Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: L1 I have not found any intormation which indicates that any of the failure criteria described in 310 CNIR 15.303 or in 310 CNIR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System Conditionally Passes: t " One or more system components as described in the "Conditional Pass' se:tion need to be replaced or repaired. The system. upon completion of the replacement or r¢pair, as approved by the Board of Health. will pass. Answer ves, no or not determined (Y,v,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 a.s 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: Page 3 of l I OFFICIAL INSPECTION FORINI - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FOR T PART A / CERTIFICATION (continued) Property Address: G 5 ` (OLD S' t�_ RW Q. v�1 Owner: Q- IYI)4%. Date of Inspection: .�' Further Evaluation is Required by the Board of Health: 1" + Conditions exist which require further evaluation by the Board of Health in order to determine if the system is ailing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CNIR 1-5.303(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 3. 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 environmem: _ "Che system has a septic tank and soil absorption system (SAS) and the SAS is within t00 feet of a surface water supply or tributari to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone t of a public barer 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. br 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: I , Page 4 of t l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (con(inued) Property :address: 6,o OLO ST 'L Rol,j Owner: — � Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding ofetfluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool }� Liquid depth in cesspool is less than 6' below invert or available volume is less than ! day flow Required pumping more than 4 times in the last year �iOT 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 ofa surface water supply or tributary to a surface water supply. .-env portion of'a cesspool or privy is within a Zone 1 ofa 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 D.EP 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,`-o)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNIR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 apd to 15,000 gPd• You must indicate either"ves" 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 ofa 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 public water supply well P PP Y Ifyou'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 Ctv1R 15.304. The system owner should contact the appropriate regional office of the Department. i Page 5 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESStNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6S- OL L_��� Owner: Date of Inspection: Check if the following have been done. You must indicate "yes" or"no" as to each of the followinu: Yes No _ Pumpim, information was provided by the owner, occupant, or Board of Health )C 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 X Have large volumes of water been introduced to the system recently or as part of this insp:"ion '? K Were as built plans of the system obtained and examined?(ff they were not available note is N/A) W'as 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 fer the condition of thebaffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth )f scum ? /� _ Was the facility owner(and occupants if different from owner) provided with information in 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: Yet 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 CAR 15.302(3)(b)] Pa__,e 6 of t OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART C SYSTEM INI FORINIATION Property .Address: �`J "' �i ROJ (' 2nTI1yt 1 Owner: STe Date of lnspection: (,W-10I �I FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design):.13 Number of bedrooms (actual): 3 DESIGN flow based on 31,Q CNIR 15.203 (for example: 110 gpd x A of bedrooms). v 0 Number of current residents: Does residence have a garbage grinder(yes or noA0 [s laundry on a separate sewage system (yes or no):(la [if yes separate inspection required] Laundry system inspected (yes or no):_ Seasonal use: (yes or no): M Water meter readings. if available (last 2 years usage(gpd)): A Sump pump (yes or no): _ Last date of occupancy: �,( T. C0titMERCIAL/I-iDUSTRIAL Type of establishment. Design flow (based on 310 CNIR 15?03): g p d Basis ofdesign 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: _ 1� N_Jy e) 51�� � �- Was system pumped as cart Oft he inspection (yes or no): YCZS, f If ves, volume pumped: ��_gallons -- How was quantity pumped determined? -rc r_4 Reason for pumping: C(,)AMe,— re4UZSr T_YSE OF SYSTEM Septic tank, distribution.box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privv 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 if allomponents, d atp installed (if known) and source of�'nformation:' �r Were sewage odors detected when arriving at the site(yes or no): �� - i Pa,je 7 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f_ SYSTEM IN/FORMATION(continued) Property :address: V o� lCt- �d Owner: STQ V�4' Date of Inspection: Qljt4JA 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 ofjoints, venting, evidence of leakage, etc.): pl t�rw�� 0 SEPTIC TANK: �/(locate on site plan) Depth below grade: � Material of construction: concrete+metal _fiberglass _polyethylene _other(zxplain) It tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: Sludge depth: rr Distance from cop of sludge to bottom of outlz[ tee or baffle: 6' 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: Q Flow were dimensions determined: T. C- _ t Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): (\ 1(1kJclu GREASE TRAP:kKocate 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.): P"we8of ( l OFFICLAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � y� � �r t�L• Owner: She�}'�&•� �,t�4 ,, Date of Inspection: TIGHT or HOLDING TANK:/ (tank must be pumped at time of locate ins ection p )( on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polvethylene other(explain): Dimensions: Capacity: -jallons Design Flow: 7allons;dav 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: " (ii present must be opened locate on)( site plan) Depth of liquid level above outlet invert: ' Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 1 I \ t / ' _ PUMP CHAiMBER: -(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.): Page 9 of I l OFFICIAL INSPECTION FORINI — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTENT INFORMATION (continued) Property address: 6 T ��- Owner: S G� Date of Inspection- SOIL ��Z z1ocate ABSORPTION SYSTEM (SAS): on site plan, excavation not required) If SAS not located explain why: Type leaching pits. number:_ leaching chambers. number: eaching galleries, number: leaching trenches, number. length: leaching fields, number, dimensions: overflow cesspool, number: innovative%al tern ative system Type!name of technology: Comments (note condition of soil. signs of hvdraulic failure, level of ponding, damp soil, condition of vegetation, etc.): G __ 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 laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil. signs of hvdraulic failure, level of pon din g, condition of vegetation, etc.): PRIVY: (locate on sits plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE1vI INFORINTATION(continued) Property Address: �J 5 / �L� ST�9L�U Owner: STC Coll2r 0 Date of Inspectlion: Q 1 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 -fro 1 ia y � Pane l 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C J SYSTEM I IFORIIATION (continued) Property Address: / L10 Owner: /ylG Date of Inspection: d 1 SITE EX--k 1 Slope V/ YOS Surface water ✓ no Check cellar V 07 n Shallow wells t/ j Estimated depth to ground water I� feet Pease indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of desisn plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach doc entanon) �-.accessed USGS database-explain: cr,\STatL 04 You must describe how,you established the high ground water elevation: LOC,-t 11 f 5/25/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, /�-� 4e,�. , L�/K ✓ hereby certify that the engineered plan signed by me dated G concerning the property located at meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using, the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS information) I L B) G.W. Elevation + adjustment for high G.W. — 1 DIFFERENCE BETWEEN A and B SIGNED : DATE: v 1710 NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder: percexmp COMMONWEALTH OF MASSACHUSETTS f' EECUTIV OFFICE OF ENVIRO1�t'AdEh'T�?,1., dkF�'AIRS Yj W DEPARTMENT OF ENVIRONMENTAL P'IROTECTION c RECEIVED AUG 7 2001 TITLE 5 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORNI — NOT FOR VOLUNTARY ` ' SUBSURFACE SEWAGE DISPOSAL SYSTEM :FORK-1 PART A CERTIFICATION Property Address: Owner's dame: STe o)Ai Owner's Address: S fC,,, locJ ell Qr✓!l . Date of Inspection: f G r N atne of Inspector: (please print)_ �� Nww Company game: WIND RIVER ENVIRONMENTAL Mailing:address: 561 MAIN STREET fIUDSON,CIA.01749 Telephone Number: 1-978-562-4500 CERTIFICATION STATEMENT I ertiN that I have personally inspected the sewage disposal system at this address and that the information reported b+:law 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 disposa: systems. I am a DEP approved system inspector pursuant;7Passes ction 15.340 of Title 5 (310 C`7R 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: � Date: 7 /� Ql The system inspectorshall 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 irspector and the system owner shall submit the report to the appropriai:e 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. `ores and Comments i *'* 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 condition's'6f use. S j •1 Page 2 of t 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A (�,1 CERTIFICATION (continued) Property Address: 6S 9 oz o S 7-4 Owner: STe y C-' Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A., System Passes: V I have not found any information which indicates that any of the failure criteria described in 310 CMR 13.303 or in 310 CN4R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: C nTd,, B. �Syystem 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 r pair, 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 extiltration 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)n Property Address: S Q�. ��� t_ ' of STi) Owner: Q. CIA tent,� Date of Inspection: S her 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 ailing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CINIR 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. Svstem 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: Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6o OLO ST-a*- A04d Owner: &TL ,1164 Date of Inspection: S� G 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 54 Liquid depth in cesspool is less than 6" below invert or available volume is less than 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. Anv portion of/a cesspool or privy is within a Zone 1 of a public well. — vy is within 50 feet of a private water supply well. Any portion of a cesspool or pri Any portion of a cesspool or privy is Iess 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.) qVo (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CNIR 15.303. therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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. Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / CHECKLIST Property Address: ` OLD Owner: Date of Inspection: 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 X 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 ? X Have large volumes of water been introduced to the system recently or as part of this inspe-,tion ? 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 i' X _ 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: Y no J� 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 CLviR 15302(3)(b)] Page 6 of l l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c SYSTEM INFORMATION Property Address: v 17 60 S A-),c­ '( of - Ter�n 1 Owner: STe�� Date of Inspection: FLOW CONDITIONS RESIDENTIAL `J Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x##of bedrooms): 33 Number of current residents: Does residence have a garbage grinder(yes or no)AD Is laundry on a sep..irate sewage system (yeses or no):fZ [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): AO Water meter readings, if available(last 2 years usage(gpd)): J h b Sump pump (yes or no): Last date of occupancy: L(, T COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CNIR 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: N T Vow) 1lku- Was system pumped as art oft e inspection (yes or no): QS, If yes,volume pumped: 1600gallons--How was quantity pumped determined? I� Co14 , Reason for pumping: CQ5jCjne­ rXiiyeST. WE 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, datk installed (if known) and source of' formation: Were sewage odors detected when arriving at the site(yes or no):�1b - Pave 7 of l 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN/FORMATION(continued) Property Address: 60 OLQ S 'L /l4 TeAW Owner: STe 6, Date of Inspection: BUILDING SEWER (locate on site plan) / /40 Depth below grade: M aterials of construction. _cast iron PVC_other (explain): Distance from private water supply well or suction line: Comments on condition of joints, venting, evidence of leakage, etc.): ply �a 0 K. SEPTIC TANK: (locate on site plan) Depth below grade: 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: 'x 1-k S Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: O( Scum thickness: ��- v Ie- Distance from top of scum to top of outlet tee or baffle: r� Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Ike-';3 tt) WITS T7i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 11 17 GREASE TRAP:kgocate 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.): Pa,—Ye 8 of 1 1 OFFICIAL INSPECTION FORINI —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (, 9L- Rj. Owner: Date of Inspection: TIGHT or HOLDING TANK:a (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: "viaterial of construction: concrete metal fiberglass_polyethylene other(esplain): Dimensions: Capacity: gallons Design Flow: iallons"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 resent must be o ened locate on site plan) P P )( P ) Depth of liquid level above outlet invert.- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): eG.y r l '/ PUMP CHAMBER:" -(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.): Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOnORMATION(continued) Property address: ��� �L� S7 Owner: S �' e1 Date of inspection: 2�S '�/ SOIL ABSORPTION SYSTEM (SAS): v {locate on site plan, excavation not required) j { If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: eaching 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.): 5t�� of— kydvr,./tcL 00- CESSPOOLS. T' (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 laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hvdraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:ft(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.): Page 10 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: v "/ OL-0 S-rc, STCOwner: o Date of Inspection: GQ f 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. d r. 'fro ;Jed w � la � (� ok Page 1 I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 66-9 SY/STEMCIINFORNATION (continued) Propem Address: L-10 J5`"yp- d ?r� Owner: Date of Inspection: O SITE EXAM Slone 7 YG5 Surface water no Check cellar V 07✓ (1 Shallow wells 6 Estirnated depth to ground water 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: Checked with local excavators, installers-(attach dot entation) .accessed USGS database-explain: i You mot describe how you established the high ground water elevation: r II 5/25/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, / 1(� 4e�I ' L -�✓ , hereby certify that the engineered plan signed by me dated 0 G� , concerning the property located at 65 04e s ra, Rbc meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A To of Ground Surface Elevation "p l atlon (using GIS information) 4 B) G.W. Elevation + adjustment for high G.W. _ L l DIFFERENCE BETWEEN A and B SIGNED : DATE: U 7.0 NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:percexmp ISy OF,.aAjZ;4S. . rr CERTIFICATE OF ANALYSIS Page: 1 w t� Barnstable County Health Laboratory Report Dated: 11/12/2004 Report Prepared For: John Viola Order No.: G0428215 Viola Associates I I O:Rosary Lane,Unit A Hyannis, MA 02601 Laboratory ID#: 0428215-01 Description: Water Sample#: 2821501 Sampling Location 126 Great Bay Road Osterville MA Collected: 10/5/2004 Collected by: A Viola Guest House Received: 10/5/2004 Test Parameters ITEM RESULT UNITS RL MCL Method# Analyst Tested Note LAB: Metals Iron 0.25 mg/L 0.1 SM 31 I1B LAP 11/4/2004 Manganese 0.57 mg/L 0.01 SM 3111B LAP 11/4/2004 Laboratory ID#: 0428215-02 Description: Water Sample#: 2821502 Sampling Location 126 Great Bay Road Osterville MA Collected: 10/5/2004 Collected by: A Viola Tennis Court Received: 10/5/2004 Test Parameters ITEM RESULT UNITS RL MCL Method# Analyst Tested Note LAB: Metals Iron 2.7 mg/L 0.1 SM 3111B LAP 11/4/2004 Manganese 0.42 mg/L 0.01 SM 3111B LAP 11/4/2004 Approved By: _ If (Lab erector) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE Date: , TOXIC AND HAZARDOUS MATERIALS ON—SITE INVENTORY NAME OF BUSINESS: A } AA Aakro Tr4,^s r o r-+ BUSINESS LOCATION: 6 S 7 00 J 5-�,k`e- R) �e-��°��`)�- A INVENTORY MAILING ADDRESS: S-7 old S-%,,5A R)• Ce-. u, Ilr _ oib �z TOTAL AMOUNT: TELEPHONE NUMBER: SOV- CONTACT PERSON: A,ALAs/ EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: kko �C'raNs r INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: "I Last shipment of hazardous waste: IVIA Name of Hauler: ��� Destination: 1111A Waste Product: 'III Licensed? Yes No JVJA NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers N o (�tiz&Ir J OVS, A-4-vr"e,Is UWJ . 0'r- (including bleach) sa�re� a4 PAX4�� Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No. - ��� Fee -,Iy THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pphration for )Diopozal bpztem Con,5truction Verrnit Application for a Permit to Construct( )Repair( )Upgrade(v4Abandon( ) EJ Complete System Madividual Components Location Address or Lot No. (y 57 M_V,A9�e— ; Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 0—C 4 V.0-S-0P�'ld= /-5—l®ut � 9 I Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow © gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank O'S k 54 A Type of S.A.S. ajC, Csr IX-C i t:!j Description of Soil A� v_ Nature of Repairs or Alterations(Answer when applicable) ` 'aa-S`f 19.f I ®f-t— �i S���'t :too i S i- 4�G' " S' 6 k C".c 6r c i- 6 G ec 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 b a Signed Date ' Application Approved by - Date % 1�4 -10ci Application Disapproved for t e foll ing reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS_ 2ppYication for.Migogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System N6dividual Components 44 Location Address or Lot No. ofo r ` Owner's Name,Address and Tel.No. C�IVTeuu`+11`Q Assessor's Map/parcel t q t—Q(E; Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �S-/QL,l t, Type of Building: Dwelling No.of Bedrooms Lot Size sq.--ft. Garbage Grinder q ) _ Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 30 gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title _ f 1. Size of Septic Tank �tC i S t d' jr)rx)LI 0 i -v Type of S.A.S. K u D4 rl-UI " c c L, r Description of Soil 'tl Nature of Repairs or Alterations(Answer when applicable) yc. S 1)A_ d OF-,= Tr Gels t c. dv r ' t G C A - 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 b!eFi-h34k�s- . Signed Date Application Approved by 0 Date f—i V Application Disapproved for foll ing reasons Permit No. y- /_r.. Date Issued y' --------------------------------------- f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance i THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( to Abandoned( )by jm _ � at ,e. QQ, C C—hf t t has been constructed in accordance with the provisions of Tide 5 and the for Disposal System Construction Permit No. - G dated Installer 1 Designer ,. The issuance of this ermit s all not be construed as a guarantee that the sy tem,will function Ades d. Date f Inspector AAA ff � �. ✓1/ �°, ��� � -----------------------------'✓---------- No. �Z T — ('�C4..� Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migpogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrad ( an ( ) System located at S 2 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: — ( N �1 Approved by�. � r\ 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) herebythat the a cert'ify/ pphcatlon for disposal works construction permit signed by me dated g`l7_ �cj concerning the property located at meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the r� pe colation rate is less than or equal to 5 urinates per inch. v There are no wetlands within 100 feet of the proposed septic system //• There are no private wells within 150 feet of the proposed septic system l/• There is no increase in flow and/or change in use proposed There are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] (((//// If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: ? /� A) Top of Ground Surface Elevation(using GIS information) ✓�`� B) G:W. Elevation +the MAX. High G.W. Adjustment .@ _ J DIFFERENCE BETWEEN A and B a—1 SIGNED DATE.- (Sketch proposed an of system on ackl. q:health folder.cert t i►'� a. �� �� ��� G U . - �amrrr_�_. •rx�ac-�— . RA5(Qr.0 1 � 1 FEB Fl 1 ,ZIZ Fir_ _ Ll "ll zsa�cl(n� -rca�_/zsara-/�za�w— Bar- .t � E FO I mm, JINO i �— _ Q - ,1 .1 , 11� v2 31 _ . I I — f 0 I i L L p_11G O T. - - w D O NcnccC &C rr_ I I —6E1S2>56R4-- I 24 ,Vi Ho ----14, I 1 D W i O I tl .E�tvilC" -:_ I I d I 2 f� � —'�>•�-Eou�n i _ I 1 P. I � 2 � I' I I _B'-iR�Gl6175-'ou 1:6'.Q^ 1 _ one. 7 3LL7'S3✓�YaII^�-c7Si17lcso2 � V ------ --� _._.. .. e..w,n.m+...ow { I 1�\ ---- '•� ism 1 is Val ®C"_3StS:_�n l^�n—im—acQR`Q6ccc—a e2:i.16om'., -... 1 u "Pt1�cE.$ES?ts�r,tre�e•1 Ccano �'. . C9>,ss��8 ?; StL.uyRi ' t .. �'a.• .. \ �• Y� - - - . _ ,t� •y�. S - .- _ _��sic'-•'__-__ �".�. - i:: .- -UfaTIOW�V'. �xa-- \ -_ •.��Y�R;•i gip. SQ:.+���-. ._ " - -- .• t ' • ASH PR .-.1 O� PaDY.QZ'i11Nr`t ` , nays\t3lS C'•o FUOq[?:/ - � - - � .' - -' _ .k BOOTS: .. .. 258'►'1wtila*�—T _i_`''! Y.i _ .1.. 1 ed4 /4