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HomeMy WebLinkAbout0111 RICHARDSON ROAD - Health 111 Richardson Road, Centerville A= aEcraFo c01� llll � m UPC 12543 o No. 53LOR �t�n.coN��� HASTINGS. MN TOWN O�F��``BARNSTABLE LOC.A.TION W Rt " `..A�e�, `Z!l • SEWAGE # VILLAGE� � ll,,Q i - ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 leaching facility) Feet Furnished by Ell fl 4q -39 4LI S iy d 4p ust" �0 12c c �ir fi W , fig. epK: r oi) Map I® z* Parcel . I Peimit# . �V House# ��� ' Date Is ed Y Q_ .. Board of Health(3rd floor)(8:15 9:30/t-1:00-+A 1'.`'v p Fee.; P Conservation Office(4th floor)(8:30-9:30/1 00 �2 00) Zt1� ®S� Q, I� �I �dy Planning Dept.'(19t floor/School Admin Bldg.) Definitive P+ 1Zy Planning Board 19 } : BARNSTABU. r - MASS . TOWN OF BARNSTABLE PC Building Permit Application Project Stre}� ress ��J /Ct/®¢/� 5'�J .6 E6 Village Owner� / /�S. �� a/?.I�.�I S Address ` .,Telephone ' 6201? 2°°u-'� 667( l .Permit Request OV111 X /a %klor— :First Floor �/'9� square feet Second Floor �% square feet 4 Construction Type_412d�= Estimated Project Cost $ �OO Zoning District Flood Plain Water Protection AJZ Lot Size //T onm Grandfathered ❑Yes ❑No Dwelling Type: Single Family . Two Family ❑ Multi-Family(#units) Age of Existing Structure 15' Y 16-S Historic House ElYes )0 No On Old King's Highway ❑Yes *�No Basement Type: )Q Full ❑'Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) NO A F Basement Unfinished Area(sq.ft) 9U Number of Baths: Full: Existing 7— New O Half: Existing O New No.of Bedrooms: Existing New 0 Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: lW Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes No Fireplaces:Existing New, O Existing wood/coal stove ❑Yes No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) ❑Barn(size) ❑None V Shed(size) x 6 ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded Ll Commercial ❑Yes $NA If yes,site plan review# Current Use `!1Z61 beA-1C(C Proposed Use w Builder Information p _ Name ,9-H.AJ r eUI-4.l 0q-0 Telephone Number SO a- 77 Address I Aa mretu bl kg (/✓, i, License# tS 9, '2 3 3 i r 7 b Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PE MI DENIED FOR THE FOL REASON(S) F> t; �1 AOAD 71-24 a' I M Lu / S.; Z_ `J Ieo S rb ° QecK llu O I Pnc kEAc I-1 A P(T /S0,44 t, PLAN OF LAND " r IN CENllVILL� D/STD)C T ,QAX VSr,491—ie; I-IA 5.5 SCALE: I INCHX 30 DATE :OC7... 30) 1996 MASS BAY SURVEY INC. ?AUIJ. y NEWTON , MASS. SAWTELL , No.9747 A REFERENCE : RECORDED IN THE 46AAA1_f7AB446* COUNTY REGISTRY OF DEEDS PLAN. BY407W 7NC. Rf-BOOK /004_PLAN .PAGE_. .64 DATEOf1�8 I HEREBY CERTIFY THAT THE BUILDINGS ON THIS PLAN ARE LOCATED ON THE GROUND AS SHOWN , AND CONFORM TO THE ZONING LAWS OF THE TOWN OL .BA•4N.fTX�.S'LE' I CERTIFY THAT THIS LOCUS IS NOT WITHIN THE FLOOD HAZARD ZONE AS- DELINEATED ON MAP —COMMUNITY PANEL 2!.5'000/ 0005C . ZONE C THIS PLAN WAS NOT MADE FROM AN INSTRUMENT SURVEY AND IS FOR THE USE OF THE BANK ONLY ; NOT TO BE USED FOR FENCES,WALLS, ETC. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms,rnaynot be altered in any way. A. General Information A'Z410 /.16 Important: When filling out 1. Property Information: ��°��✓ b�� forms the computer, r,use only the tab key Property Address to move your cursor-do not Owner's Name use the return key. /��SU/l� 41 GG/2 �'C !/P A*f Owners Addre Cityrrown State Zip C de � - Date of Inspection: 2 Date � 2. Inspector: 4f—�,0A1'4 40 4' 27'01A— Name of Inspector S �vi2 A1! Company Nam z9 Company Address City/Town �i Stater Zip Code Telephone Number B. Certification I certify that I have personally inspected the sewage.disposal system at this address and that'the information reported below is true, accurate and complete as of the time of the inspection. The:inspection was performed based on my training and experience in the proper function and matr tenance of on'site �;m-s sewage disposal systems. I am a DEP approved system inspector pursuant to-Section 15.340?.of Title 5(310 CMR 15.000).The system: - Passes ❑ Conditionally Passes ❑ Fails ❑ Need Evalu I by t tol Approving Authority ' i Inspifto i ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. („/glem� t5insp.doc.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewag Disposal Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) ,��� ���-1ST Property Address Ae - OZG 3z Cityrrown State Zip Code Owners Na Date of Inspection 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. / J Comments: �j y-P C+u/c c / z41 7��71,�v y B) System Conditionally Passes: As 4k—ze /� ❑ One more system components as described in the"Conditional Pass"section need to be replace epaired.The system, upon completion of the replacement or repair, as approved by the Board of h, will pass. Answer yes, no or not deter ed (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 ars old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantia Iltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tan 's replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structura ound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years is available. ND Explain: t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts u Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �y B. Certification (cont.) Property? roperty dress err/ DZG�Z City/Town State Zip Code ✓r-1 4'- z y-oq Owner's game Date of Inspection d� B) System Conditionally Passes (cont.): ❑ bservation of sewage backup or break out or high static water level in the distribution box due to roken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pa inspection if(with approval of Board of Health): ❑ roken pipe(s) are replaced ❑ obs ction is removed ❑ distributio box is leveled or replaced ND Explain: ❑ The system required pumping more tha 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approva f the Board of Health): Q broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ ' ions exist which require further evaluation by the Board of Health in order to determine if /J. the syste ' failing to protect public health, safety or the environment. 1. System will pas less Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sys not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a su ater ❑ Cesspool or privy is within 50 feet of a bordering vegetated d or asalt marsh t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) Property Address Lc� �z evZG 3z. City/Town State Zip Code oY�is 4,-- Z 9-a9 Owner's Kame Date of Inspection ,l C) Further Evaluation is Required by the Board of Health (cont.): 2. System wi it unless the Board of Health (and Public Water Supplier, if any) determines that a system is functioning in a manner that protects the public health, safety and environ nt: ❑ The system has a tic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface r supply or tributary to a surface water supply. ❑ The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS ' within 50 feet of a private water supply well. system has A i❑ The syst aseptic tank and SAS and the SAS s less than 100 but 50 feet or more from a private water supply well**. Method used to determine distance: **This sys asses if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates ent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provide t no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) Property Address ��;;erli�� �� GZC3Z Cityi I own State ZipCode arras 4 'Z 9—�9 Owner's NaFne 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 ❑ 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 Y2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ jP 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. ❑ ] o��¢ 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. ❑ A1,4 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ jvI The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 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. t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4 B. Certification L(cont.) Z/ z /G�/d l-of s C/y Property ddress i— Cityrrown State Zip Code Owner's Name Date of Inspection E) arge Systems: To be considered a large system the system must serve a facility with a Al desi low of 10,000 gpd to 15,000 gpd. For large s ms, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Sec D. YES NO ❑ [ ] the system is withi 00 feet of a surface drinking water supply ❑ © the system is within 200 feet of a tary to a surface drinking water supply ❑ the system is located in a nitrogen sensitiv a (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public w supply well If you have answered "yes"to any question in Section E the system is consider a significant threat, or answered"yes" in Section D above the large system has failed. The owner or o rator of any large system considered a significant threat under Section E or failed under Section D sha rade the system in accordance with 310 CMR 15.304. The system owner should contact the appr iate regional office of the Department. t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist Property Address C City/Town State Zip Code Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: YES NO ❑ F� 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? ❑ [ J 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) ( I ❑ 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,� 4-61e SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: [ ] ❑ Existing information. For example, a plan at the Board of Health. !� ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts u Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M D. System Infor at'on Property ress y� .ate le,, ✓,/l City/Town State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): — Number of bedrooms (actual): —�— DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33d Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] 'Yes ❑ No Laundry system inspected? ❑ Yes NoA4�- Seasonal use? ❑ Yes No Water Zia meter readings, if available (last 2 years usage(gpd)): a u Sump pump? 730 �tso,&Z C ❑ Yes No Last date of occupancy: "7 Co rY"e7� Date Com=Estab ustrial Flow Conditions: Typeent: Design flow(based on 310 C .203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., e Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) Property Address City/Town State Zip Code 4; d .29- 09 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? DQ Yes ; ❑ No If yes, volume pumped: -- gallons How was quantity pumped determined? �� � 3D- Reason for pumping: 1 VV/Cc 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) El 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 'f known)and source of i f rmation: 2e ke l/ � &/ --� a i Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 41y D. System Information (cont.) Property Ad ress �r DZ�3z Citylrown State Zip Code Owners Name Date of Inspection Building Sewer(locate on site plan): > Depth below grade: feet Material of construction: cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: P Pp Y feet����d, Comments n conditio joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): / 2 Depth below grade: feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) f DD �� �li �) S C•nLC� If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ NoW-JJ4 certificate) I / Dimensions:4f �G —G k S � 7P /D Sludge depth: Distance from top of sludge to bottom of outlet tee o ba le Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4M D. System Information (cont.) Property Address City/Town yy�f State Zip Code Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, li id levels as relat d to outlet invert, evidence of leakage, / -&V Z'd' GJ / ease Trap(locate on site plan): Aepth be grade: feet Material of cons tion: ❑ concrete ❑ m I ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle conditio structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tig Holding Tank(tank must be pumped at time of inspection) (locate on site plan): 4 Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglas ❑ polyethylene ❑ other(explain): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M D. System Inform tion (cont.) �,. � Property Ad e p Y ss Qy�J2yy City/Town State 2� b9 Zip Code Owner's Name Date of Inspection /1/Wf T' ht or Holding an (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: larm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached?/ El Yes El No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any ev'den of ea age in o or o of box, tc.). / // &dump Chambert{le a on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ No t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) z /- Property — a� 1�2G 32 City/Tow State Zip Code "0 0 . Owner's Name Date of Inspection /v�Comments r dition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): 4?SAS,r)rfocated, explain why: �Gd ; c��/QreL✓J �„� �a S�1—�C� l Type: leaching pits number: /0511 ❑ 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 c ,itt. n of foil, signs hydrauli failure, lev f pondi g, d mp soil, condition of vegetati , etc.): �r Ci`` � UYIIl� �U�te / LIZ144 AV wit¢�vc p/& A'V y ��� t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Informati n (cont.) Property Addr s§ CitylTownA. Stat6 Zip Code Owner's Name Date of Inspection 19esspools (cesspool must be pumped as part of inspection) (locate on site plan): Number d configuration Depth—top o iquid to inlet invert Depth of solids laye Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydrau I ailure, level of ponding, condition of vegetation, etc.): /1A Privy (locate on Ian): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic ilure, level of ponding, condition of vegetation, etc.): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) Property A dress City/Town State Zip Code �vYr�s "g- :5 o� Owner's Name Date of Inspection 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: 7Z—T a '67 v t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) Property City/Town State Zip Code mzu Owners Name Date of Inspection Site Exam: Slope D 2 Surface water Check cellar Shallow wells `2 �?pt� a tC -- Y�Z z 461.zl �117�- Estimated depth to ground water: ZZ) / Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) [� Chqqked/with I cal Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You mu describe how you established the high ground water elevation: t5insp.doc.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Commonwealth of Massachusetts Executive of Environmental Affairs DEP Department of Environmental Protections SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - -._ - - - - PART - CERTIFICATION Property Address: V�_D Q.cd- Address of Owner: A,P O A (if different) ao v�e.t Date of I nspection. �����tiltary , '"A CAZ-Z % k �'s k t. Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 • M ashpee Ma 02649. Tel : (508) 4771420 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system XPasses ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority. --- Fails Inspector 's Signatur . ( Date: t t�S�SL The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owners : Qo;Cc ,,�-, Date of Inspection : INSPECTION SUMMARY: ._----.._--- Check A, B, C, or D A)SYSTEM PASSES: •�l have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated",explain why not. -••• The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of i Health. -•-• Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). ----• broken pipe(s) are replaced --- obstruction is removed -••- distribution box is levelled or replaced --- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): -•--- broken pipe(s) are replaced -••-• obstruction is removed G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Q Owner : Date of Inspection : C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: --• Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health ,-safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: --- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IFAPPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. -- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. •--• The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. --- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. -•- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 3 i 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (IL 1 Owner: Date of Inspection D)SYS T E M FAI LS (continued) -- 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 over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. --- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). number of'times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I of a public well. -- Any portion of a cesspool or privy is within 50 feet of a private water supply well -- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana- lysis. 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. H SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address.- Owner: Prurb Date of Inspection : ` ,\ E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- the system is within 400 feet of a surface drinking water supply --- the system is within 200 feet of a tributary to a surface drinking water supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - f WPA)or a mapped Zone 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Cp�� - Date of I nspection:_l 1\c.\5 L Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks ! and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. -x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x AB system components,excluding the Soil Absorption System,have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. --x The size and location.of the SoR Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: e'c4V,\Vv Owner: ►fits Ct,,ti Date of Inspection: RESIDENTIAL: Design flow : gallons Number of bedrooms : o z_> Number of current residents: C:> Garbage grinder (yes or no) : tN O Laundry connected to system(yes or no): tAeS Seasonal use (yes or no) : t�- Water meter readings, if available: 'N�r Last date of occupancy : COMMERCIAL/INDUSTRIAL : Type of establishment: Design flow : gallons/day Grease trap present: (yes or no) Industrial waste holding tank present (yes or no) : Non-sanitary waste discharged to the Title 5 system (yes or no) : Water meter readings,if available : Last date of occupancy : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PU M PI N G R�QQ R D�S and source of information: �v 4..'l�r4tc�.�Q.. Q.Vv..\fi. .... System pumped as part of inspection(yes or no) :....A.c�)...... if yes,volume pomped : .................... gallons Reasonfor pumping :............................................................................................................ T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ill f-AcV\C,,-h4r.-av1J Owner: /Q-jCol Date of inspection: TYPE OF SYSTEM kSeptictank/distribution box/soil absorption system --- Single cesspool ••. Overflow cesspool -- Privy ... Shared system (yes or no)(if yes, attach previous inspection records, if any) ... Other (explain)........................................................................................... APPR QXI MAT E AG E of all components, date installed (if known)and source of information . .n..o .:.�°t �.... ..�s .............................................................................. ................................................................................................................................................ .......................:........ Sewage odors detected when arriving at the site : (yes or no).... SEPTIC TANK (locate on site plan) Depth below grade: .L�..... Material of construction: .... concrete ......... metal ........ FRP ........ other (explain) . ................................................................................................................................................ Dim .0 ensions: .-x5 Sludge depth:..0"...... i r Distance from top of sludge to bottom of outlet tee or baffle:...3 ................... Scum thickness :... r� Distance from top of scum to top of outlet tee or baffle: ...............(Z.................. Distance from bottom of scum to bottom of outlet tee or baffle :........I-( .Q Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural inte i ,evidence of leakage,etc.)................ ..... s�.... �. i.iu . . .�t-�,...... tLjc�. .i ....... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C j SYSTEM INFORMATION (continued) I Property Address: k( I Owner: Qcl Date of inspection: \s� GREASE TRAP : ... flocate on site plan) i Depth below grade: ............... Material of construction: ........concrete. ........metal........FRP........other(explain).... i ........... .............................................................................................................................. , Dimens.ions:.................. Scum thickness:........................ i, Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ ................................................................................................................................................ . ................................................................................................................................................ TIGHT OR HOLDING TANKS:..r\\?)... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ ................................................................................................................................................ 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: ; Date of inspection: ��\S�`►1 DISTRIBUTION BOX:..�PS (locate on site plan) Depth of liquid level above outlet invert:....,; 43TCA Comment: (note if level and di�tribut' n equal evidence of solid arryo er, evidence of leakage int or out of box, etc.)... . �� .�. ` � �� . t. �... . ...... ............. ........ ..� .............................................................................. PUMP CHAMBER:... . (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):.... (locate on site plan, if possible; excavat(6h not requied, but may be approximated by non- intrusive methods) if not determined to be present, explain: ........... .................................................................................................................................... ..................................................... .......................................................................................... Type: leaching pits, number: ..... leaching chambers, number:........ leaching galleries,number:........... leaching trenches,number ,length:..................... leaching fields, number,dimensions:................... overflow cesspool, number:.......... Comments: (note ndit' of soi! , signs by uli fail e, level of ponding ndition of eg ati C.). ... o .. .. .. i t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 1 eCVd� Owner: Ac\j&,t3 Date of inspection: 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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) .. ........................... Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ . ................................................................................................................................................. PR IVY l (locate on the site) Material of construction: ..............6.................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) ................................................................................................................................................ . ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : Owner: AA� Ccp�t i Date of inspection: \jt51(�6 I SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' i 11 \ Z az - ys 14 r DEPTH TO GROUNDWATER: Depth to groundwater: .7 d.feet Method of determ*at*or approximative: �.�S.:.�•��s�l. �. ............... .. .. .. ........................................... ........................................................................................ a � 0............ .. THE COMMONWEALTH OF MASSACHUSETTS / BOAR® OF HEALTH .........................OF.............--- . ....._... ...------ ......................... Apphration for DiopuoFai i0orkii Tonotrurtiun Vamit Application is hereby made for a Permit to Construct 4___) or Repair ( ) an Individual Sewage Disposal System at: Location-Address Q�� or Lot No. r\ Owner Address W Vr�.a. ........,... ! t.�£ .� ............ A a Installer Address dType of Building Size Lot...L�3_f'.CI V......Sq. feet V DwellingZ;No. of Bedrooms_______________________N_0............Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building g Gr!1JLM'Z-------- No. of persons____________________________ Showers Cafeteria ( ) Other fixtures . ------------------------------------------ ..................gallons. WSeptic Tank—Liquid capacitvkFF�__gallons Length........ __. Width......T...... Diameter________________ Depth................ x Disposal Trench—No_____________________ 1?6idth.................... Total Length.....................Total leaching area.........._.........sq. ft. Seepage Pit No.......[............ Diameter._:_._ ...19 Depth below inlet...... ............ Total leaching area.__zQQ.....sq. ft. Z Other Distribution box Dosing tank ( ) •� 1 ~' Percolation Test Results Performed by............ _ ., ___.____._°�---..---4�!).t. Date...... _. t_,(... W Test Pit No. I..../.........minutes per inch Depth of Test Pit____________________ Depth to ground water....................... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q-L:.....L _ .7.....:0 Description of Soil..--- ........ _ A_r U :- -------------------------------- ---- -- W ----------------------------•------------•--••---•-------•-------•••----•---•--------....----•-•-------------------•-----------••-•------------••-----------•--•••-•--••-•---------------------------- U Nature 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 iITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued by the board of health. Signed........ �' ` .......... ........... Date Application Approved By___ _...__. :1.... . _____________ Date Application Disapproved for the following reasons---------------•------------••------------------------------••--------------.................................... .............................•--•--._.._......_....._..------......-•-•---•-----......_..--•--•-••...--•.._..._..__..._-•--------------•-----•--•-----------------•-•-•----------...- •----•--.... Date PermitNo......................................................... Issued...................................................... Date No..g a."-A 27=`' Fps....... ..:n........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH "1 / v •---._. 8 . . ... .. - .-- .-_...._*►_........_........ Appliratiou' for Uispoaal. Works Tontrurtion firrmit Application is hereby made for a Permit to Construct ((01j or Repair ( ) an Individual Sewage Disposal System at: ------LW 3 .t �'' tA....... ` .............. .a , ,.1 .R......... L1.!4s ....................... .ocat�ikon Address or Lot No. a Owner _w Address .......... . V .0. . �s-.-._... ................. Installer AddressPq +r: UType of Build Size Lot___. ►,C'. .....Sq. feet Dwelling No. of Bedrooms----------------------=-�0............Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building _ p ( ) ( )�]r�1.R.i1�"�-:_._-- No. of ersons__•_-..__.�________________ Showers '` — Cafeteria Q' Other fixtures ........................................... ------ - --------- --• W' Design Flow-___-__.. ► .................... __gallons per person per day. Total dail flow_____._ gallons. WSeptic Tank—Liquid capacity W _gallons ' Length:__:.__.. ___ Width...... ....... Diameter______---------------- Depth................ x ee a e ' Diameter.__:_.. ---- Total Length.................... Total leaching area....................sq. ft. sposal S Pit No.___.__ ..._..._.___ Seepage Trench— o................ Width ._� Depth below inlet...... ........... Total leaching area•__.240....sq. ft. Z Other Distribution box ( Dosing tank ( . ) � ` Percolation Test Results Performed b ............ ____ - ..........+' ...__.1.4i __ Date___....--__ `t__-1_______________ a Y .� ;�- . '-- S' Test Pit No. 1..... ________minutes per inch Depth of Test Pit____________________ Depth to ground water........:_______________. 4A Test Pit No. 2.........._.....minutes per inch Depth of Test Pit.......:............ Depth to ground water........................ ----------- - --- --•--. _... D Description of Soil____.."- _` _" �►/ .' r W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature 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 TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has jKn issued by the board of health. Signed....... ' -..-----�....._..-- .---•-•••-•-••--------•.......- " � ate Application Approved By.... ...�' --•--_._ . ----•---------------------- 1� ate Application Disapproved for the following reasons: # .............-....................... ............................•--------------------------------------....------------------••-------------.•--------------•---------------------•---..._•-•-----•-••------....---._.-- ••--•----....... Date PermitNo......................................................... Issued....................................................... Date , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..N...........OF....... .%r�• t......................................... Tnrtifirtt#r. of Tomplianrr THIS IS TQ CERTIFY, That the Individual Sewage Di osal System constructed (�" or Repaired ( ) bY-•-•-••-•-••._..�I-::�_ A.A.111:.! !1• !------------- --- -•- CL �-----------------.........------------------..............-------....._ -y Instiller at----•-•�„°� _-------•)a..........Jki4 .-�_.._ �ti�r ------------------------------•-------- has been installed in accordance with the provisions of TIT IF 5 f The State Sanitary Code as described in the application for Disposal Works Construction Permit No.80"_. .�_>_______.__. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ;�` DATE................. ...----.............. Inspector.. --�='-'-'5==--�`'=-----=--.....-t�=,z-...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ie .................OF......�r vir FEE . .......:..`.`.... �i��ro�tt1 work$ �on��rion rrani� Permissionis hereby granted...........................-•-••-T•--....•-.----•-•-._.._._•---•-••--•-._..._._..--••• .................................................... to Constr ctJ10or epa ( ) n In ividual ea age Disposal Systg at No.•--._. ......�. .... ........ �.c: �! ii- -.5� �1..........V%O.A d.-----------....•--------------------••- Street as shown on the application for Disposal Works Constructio mit No..................... ated... ...................... . � =- DATE............................................................................... BPrd Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS •.• ti l ��.�rT'�c_ -;t�=-.tom _ �So,r lSC �e a �r�6.f✓t,. - �'. ��'. x ► .o - 5G C-a.�D. �' ` (CUU►.�bh1Tl t3�� TOTAL TJEsf�►a = 425 G.P.D. ,�. � # �U f ToTA� ��c L:-r r-c._nw - 330 6.w. °` - •�� �-��TN -...,, a TA 44.,. t7f`2GDLL�TtOtJ te-&TE IQ SAAI W 02 A&A . PIT ,; r � "mot FG Top VAv K Sao.o �� ♦////� Y 11Jv.^ 97 Q� soe so.t_ 4"PPS a � f -Boy, '94.1G Sew-vt`�c 10 tNv. T-ArtK - l000 ���� (wv. wtv. gGt S'l Nc� GAL. ��.Z. PIT �' LEacN 'a WAU4F-V STOWF-- 19010 Ao ME Oiv r %SIVAIADY C-r--V--x* F iaD PLOT PL—A." Gzi9 vEL- PtZpT=-1 L LbGATI otJ E t�lT E Rol ti t.�1, `$li 1J o Sa p.t`t Gh L t�� ►N, 4T. No btu9 TEE 4-_ GG ZTtF-q, Tt-(AT T14r-- FoUM'Ppb `oN5LAOVJQ t-'1E�k t��i�.� cc�.�nt_�Y� �,�/r r�-� T't�` ,,D�.Lf►-:�� � Cv T 3 /�.IJD SFrT�?+ACID t'C-QUt�EM�1�1j'� C)l= TNC . Z'o w w ai✓ �R.i�l T A S...t �'t-/'.t1 tc. c� P -, 6 7 Rrt-C.i rC-a, i M-U a Suev�Y� Tt-�t5 PI-A" !S LIOT V ASCV u4o;"eu.k GA,J T' /iU���/l'=�{ • TI{L UFi��i=f�, rt IUIiJLD /ZNI�t 1 l�A.h,!'T' j6�M .S 1�.. • mil IT1r� ��kar C:C', caf.G�:� Y�► t?r_,:1t~,h�tt�1C.: L��Y t_iN��� — - -