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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner owner's Name
information is required for every 17 Cold Harbor Drive Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: bN
key to move your
cursor-do not Troy Williams
use the return key. Name of Inspector
Troy Williams Septic Inspections
m Company Name
19 Hummel Drive
Company Address
South Dennis MA 02660
Cltyfrown State Zip Code
(508)385- 1300 S1682
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 14, 2013
Inspector's Signatu Date
The system inspector shall submit a copy of this inspection report to the Al;PFU
ving Auth"arity( 3ard`x
of Health or DEP)within 30 days of completing this inspection. If the systeIf,)s a share�i'syste 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 gy'sterri
and copies sent to the buyer, if applicable, and the approving authority. a
****This report only describes conditions at the time of inspection and under the coVitions of use
at that time.This inspection does not address how the system will perform in thjrfuture under
the same or different conditions of use.
3
t5ins-3113 Title 5 Official Inspection Form-b u ce Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is 17 Cold Harbor Drive,
required for every Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
� III
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owners Name
information is 17 Cold Harbor Drive, Northboro MA 01532 August 14 2013
required for every g ,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
I
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is required for every 17 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*.
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate Yes or No to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is 17 Cold Harbor Drive,required for every Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s), Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, 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.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
45 Tem Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is required for every 17 Cold Harbor Drive Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Tern Lane, Centerville
M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is required for every 17 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
page. Cltyfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 12=48,000 gals.
Detail:
11=52,000 gals.
Sump pump?
❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
t5ins•3113
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"e 45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information fo is every 17 Cold Harbor Drive, Northboro MA 01532 August 14 2013
required for eve 9 +
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
NIA
General Information
Pumping Records:
Source of information:
Last pumped in 2012 per info from owner.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
p 45 Tern Lane, Centerville
Property Address M- 192 P-32-02
Alfred Morin
Owner Owner's Name
information is
required for every 17 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
page. City/rows State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank, d-box and leaching were installed on 6/24/92 per compliance
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"+
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Lines were found clear at the time of inspection
Septic Tank(locate on site plan):
'
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene
❑other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5'X9'X6' 1000 gallon
Sludge depth:
4"
t5ins•3113 Title 5 Official Inspection Form:Subsurface a Disp
osal posal System•Page 9 of 17
r
Commonwealth of Massachusetts
Rim, P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is required for every 17 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2' 8"
Scum thickness thin layer
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? probe/measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc inlet and concrete outlet tees were found present and in working order. No evidence of leakage
or damage was found. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
N/A
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 45 Tern Lane, Centerville
M- 192 P-32-02
Property Address
Alfred Morin
Owner owner's Name
information is 17 Cold Harbor Drive Northboro MA 01532 August 14, 2013
required for every ,
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑other(explain):
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A
Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments
45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is required for every 17 Cold Harbor Drive Northboro MA 01532 August 14, 2013
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert level
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.):
D-box was found level and in working order.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Tern Lane, Centerville
M - 192 P-32-02
Property Address
Alfred Morin
Owner owner's Name
information is
required for every 1 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 -6'X6' pit with
2'of stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching
trenches number, length:
�
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was found with 22"of water with a visible stain line approx. 4" higher. No evidence of
hydraulic failure or problems in the past were found at the time of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is 17 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
required for every 9
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy(locate on site plan):
� Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"e 45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owner's Name
information is
required for every 17 Cold Harbor Drive Northboro MA 01532 August 14, 2013
page. City/rown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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4 % = air 1�( -( / r
2- 2,
3 3z ado 3 ✓s� r
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owners Name
information is required for every 17 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 13.0'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 3/23/90
Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
AIW 247 Zone C 22.5' 2.4'adjustment
You must describe how you established the high groundwater elevation:
Test hole recorded on plan showed no water found at 12.0'. Hand augered 3' below bottom of
leaching with no water found at a depth of 12.5'. Groundwater adjustment at the time of inspection
was 2.4'. Bottom of leaching at 9.5'was found not to be located in the high groundwater elevation at
the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f
45 Tern Lane, Centerville M- 192 P-32-02
Property Address
Alfred Morin
Owner Owners Name
information is
required for every 17 Cold Harbor Drive, Northboro MA 01532 August 14, 2013
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
SENDER: COMPLETE THIS SECTION COMPLETE THIS SLXTION DELIVERY
N. Complete items 1,2,and 3.Also complete A. Signa e
item 4 if Restricted Delivery is desired. X ant
■ Print your name and address on the reverse Addressee
so that we can return the card to you. B. ive (Printed Name) C. D e f elivery
■ Attach this card to the back of the mailpiece, i iv
or on the front if space permits. V
D. Is delivery address different from item 1? Ye
1. Article Addressed to: If YES,enter delivery address below: ❑N
F-Alfred.Morin
17 Cold Harbor Drive 3. Service Type
fi�Certified Mail ❑Express Mail
Northboro, MA 01532 ! ❑Registered KRetum Receipt for Merchandise
❑ Insured Mail b_C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7pp9� 2820 0003 31168 1527 l -Tv
(transfer from service labeq ��
PS Form 3811,February 2004 Domestic Return Receipt tozsss o2-M-15ao
I
UNITED STATES POSTAL SERVICE
First-Class Mail I
Postage&Fees Paid I
USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
I
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l o�vn of barn stable
( � Public Health Division
_00 Main Street N
Hyannis, MA `,)2601
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Town of Barnstable
�p1HE r Regulatory Services 1OXX
� >
Thomas F. Geiler, Director � +
." Public Health Division
* BARNSTABLE,
v MASS. a Thomas McKean, Director
0.39. � 200 Main Street
�ArfD MA'S A.
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 14, 2010
Alfred Morin
17 Cold Harbor Drive 1
Northboro, MA 01532
As of October 1, 2006 a new rental registration ordinance was put into affect requiring
all property owners of rental units to register their rental units with the Town of Barnstable
Health Division. According to our records, you own the rental property at 45 Tern Lane,
Centerville. Enclosed is an application. Please use a separate application for each rental unit
you own. Should you need more applications, they are available online :at
www.town.barnstable.m.a.us. Go to the Health Division page by looking in-the Department.
Menu. There is a link to the Rental Registration information on the Health Division page. :You
may print out as many as you need, and return them to the Health Division with the appropriate
2010 fees included. This must be completed within (14) fourteen days of your receipt of
this letter.
Failure to comply with this ordinance will result in the issuance of a non-criminal ticket
citation in the amount of$100. Each day of non-compliance is considered a separate offense.
Should you have any questions, please feel free to call 508-862-4644. Thank you in
advance for your cooperation.
I
Timothy B. O'Connell, R.S.
Health Inspector
Health Division
Direct #508-862-4646
Citizen Web Request Page 1 of 2
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{ Citizen Request Management - internal use
I Request ID: 30140 Created: 4/9/2010 11:57:01 AN
_.__._.._.._____......... ................ ..........
Status: Assigned To Staff Assigned To: O'Connell, Timothy
Health Office
Anonymous: Yes Category:
Chapter 170 : Housing
Overcrowding
E.C. Date: 4/26/2010
PM
Created By: Parvin, Lindsay Citations:
Health Office
........... ..........................._.. ....... ..:...
Time Worked: 0 Response Time: 0
4
6
Requestor Details:
.........._..... .................................................... ._.._._. ______.............._..,...«.... ..._....«.._........... ._....._._.___._......-------------- ............._._..,._
Email:
.......................... ... ...
Request Location:
45 TERN LANE
Centerville, Ma 02632
Parcel Number: Map 192 Block: 032 Lot: 002
Request:
Requestor reports that the home is rental property. Requestor referred to an
advertisement which lists that the home sleeps 12 people. Requestor reports that at times 6-
7 cars are parked in front of the home.
Request Work History:
Internal Note History:
Entered on 4/9/2010 11:57:01 AM
by Parvin, Lindsay
I put a copy of the listing on your desk.
System entry on 4/9/2010 11:57:01 AM:
Assigned to O'Connell, Timothy
http://issgl2/IntemalWRS/WRequestPrint.aspx?ID=30140 4/9/2010
Health Master Detail Page 1 of 1
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Parcel: .1.32-032-002 Location: 45 TERN LANE, CENT ERVI Owner: MO SIN, ALFR D I';..3R
Business name: Business phone
Rental property: Deed restricted: F Number of bedrooms
Contaminant released: l Fuel storage tank permit:
Save Parcel Changes Return°.to Lookup
Parcel Info Parcel ID: 192-032-002 Developer lot:I._OT 11
Location:45 rERN LANE Primary frontage:
Secondary road: Secondary frontage:
Village:CENT'ERVILLE Fire district:C 0 MM
Sewer acct: Road index: 1698
Asbuilt Septic Scan: 192032002_1 Interactive map
Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT
Owner Info Owner: M€ORIN, ALFRED L JR & Co-Owner:GOEDEN, PA€OLE..I...I..E R
Streetl: 17 COLD HARBOR DR Street2:
City:NORTHBORO State:MA Zip: 015:32 County
Deed date:07/15/1992 Deed reference:8107/063
Lard Info Acres: 0.49 Use: Single Fain MDL-01 Zoning:RD-1 Neighborhood: 01'
Topography: I..evel Road: Paved
Utilities: Public Water,Gas,Septic' Location:
Construction Info 6-"king oly..r
1 11992 11661 3 Bedroom 3 Full
Buildings value: �t156,800.00 Extra features: �t19,000.00 land value: x110,000.00
http://issql/Intranet/healthMaster/HealthMasterDetall.aspx?ID=192032002 4/9/2010
Centerville Vacation Rental home in Mid Cape Cod Massachusetts MA, near beach: Short walk to private ... Page 1 of 4
Home > Cape Cod & Islands > Cape Cod > Mid Cape Cod > Centerville Vacation Rental Homes/Condos > ID 9732
Centerville vacation rental home
Contact details: Contact Alfred, by e-mail, or at phone(s): (508) 393-6968 ("Metrowest Group"), (508) 393-6968 (Horn
Please mention Property ID# 9732 from WeNeedaVacation.com! And don't forget to check availabilit
WiWa
Property ID# 9732 in Centerville view Map Centerville Info
Modern home, four bedroom contemporary ranch with spacious cathedral ceilings over great room. Finished walk-out lower
Private back yard for entertaining family and friends. Modern kitchen with everything -- including lobster pot. Deeded bead
to private area on Lake Wequaquet -- a two block walk away. Five minute drive to Craigville Beach and 15 minutes to Sand
Seashore. We provide a FREE BEACH PASS to cover parking fees at all Barnstable beaches including the famous Craigville a
Sandy Neck beaches. Walk to Public Beach on Cape's largest lake with boat launch. Five minute drive to nearby Hyannis Go
easy access to Cape Cod Malls and public tennis courts.
Relax and enjoy peaceful evenings and star filled nights on oversized private back deck. Eat alfresco under shade canopy.
This is a great central location for doing the Cape.
' -M- ' See-a full calendar with-detailed availabilit and pricing for this Centerville vacation rental.
Room configuration: 4 BRs: 2 queens, 4 twins, plus 2
sofabeds in 1 large room; sleeps 12; 2 baths
" Seasonal pricing Daily Weekly Mo
" Off-season 2009/10 $280 - $1,200 -
i Minimum stay: 3 nights $320 $1,500
Summer 2010 $2,000
Minimum stay: 7 nights
Off-season 2010/11 $295 - $1,200 -
Minimum stay: 3 nights $335 $2,200
Distance to beach Short walk to private Lake Wequaqu
beach
Time active on this website: 4 years, 10 months
VACATION RENTAL AMENITIES
walk to a fresh water beach, deck/porch/patio, BBQ-grill, washer&dryer, dishwasher, microwave, coffeemaker, linens inclu(
cable TV, VCR or DVD, fireplace, no pets, no smoking
OTHER PRICE INFO
Special Pricing for additional weeks -- 5% Discount on each successive week up to four
AVAILABILITY (contact lister)
This is a Saturday to Saturday vacation rental.
See a full calendar with detailed availability and pricing for this Centerville vacation rental.
LONG-TERM RENTAL (1 month or more)
Off season rental considered for $2000/month net of utilities.
FURTHER DESCRIPTION
We provide beach towels and beach chairs.
http://www.weneedavacation.com/Cape/9732.htm 4/9/2010
Centerville Vacation Rental home in Mid Cape Cod Massachusetts MA, near beach: Short walk to private ... Page 2 of 4
If you click on the map link at the top of the page you wil
how Tern Lane ends in a ring near Lake Wequaquet, the I
lake on Cape Cod. You will have deeded rights to this priv
little beach which is a five minute walk away. More fun fo
younger teens, perhaps, is the public beach at Lake WeqL
with lifeguards where the yellow road (Shoot Flying Hill R,
comes closet to the lake - a ten to fifteen minute walk.
If you click on map level #4, you will see how Craigville B
probably the most popular beach on the Cape, is a five m
drive and Sandy Neck Beach, with beautiful cliffside dune,
fifteen minute drive. Our FREE BEACH PARKING PASS coy
you $120 per week or more depending on how often you
the beaches.
Our house is about 10 minutes, depending on traffic, fron
Cape Cod Mall and about the same distance from the funE
shopping in downtown Hyannis. Centerville/Hyannis is the
population and retail center of Cape Cod. Tennis and golf
both five minutes away. Downcape is more quaint and rui
Fireplaced Living Room
Site seeing is everywhere depending on your interests. W
provide our guests with a package of brochures.
P 9 P 9
Testimonials:
"This vacation rental is like a "home away from home" wi
the comforts and amenities of home. Just to mention a fe
house was meticuously kept and all bedrooms had plenty
room. Having two baths was a great plus, the kitchen wa!
stocked and I can't think of anything that was missing. Gi
eating areas, large deck and table with canopy, eat in kit(
and breakfast counter. Great yard with hammock. Walkin
distance to lake and 5-10 minute drive to Craigville bea&
had a great time and look forward to renting again next y
Everyone had a great time and loved the location and am
Actually, right at this moment, I can't think of anything n-
' E that we needed for our vacation. Everything was just grei
down to the beach chairs, towels and etc. The size of you
was just perfect for my family. My children keep remindin
to make sure I let you know we are interested in renting i
Modern Kitchen with everything -- including Lobster Pot! year. Also what was great is the location, you did not hav
deal with all the traffic down towards Hyannis, Dennispori
Yarmouth." Pam C.
GUEST REVIEWS
If you stayed in this home, be the first to write one.
,s
i,
Sunny, open kitchen and dining area with sliders to deck
http://www.weneedavacation.com/Cape/9732.htm 4/9/2010
Centerville Vacation Rental home in Mid Cape Cod Massachusetts MA, near beach: Short walk to private ... Page 3 of 4
k
y.
TV a
Twin Bedroom
RsbA�
Another Twin Bedroom
r
Backyard View
http://www.weneedavacation.com/Cape/9732.htm 4/9/2010
Centerville Vacation Rental home in Mid Cape Cod Massachusetts MA, near beach: Short walk to private ... Page 4 of 4
iT .ri-�.,s ......t3 5,. r•°e`:'ai� yYtrdl `S ':H'w� d
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Nearby Lake Beach
Contact details: Contact Alfred, by e-mail, or at phone(s): (508) 393-6968 ("Metrowest Group"), (508) 393-6968 (Horn
Please mention Property ID# 9732 from WeNeedaVacation.com! And don't forget to check availabilit
Home > Cape Cod_& Islands > Cape Cod > Mid Cape Cod > Centerville_Vacation..Renta_l Homes/Cond.os > ID 9732
Home : Cape_Cod Rentals : Florida Rentals : Client Login : Add Your Property : Privacy.Policy : Resources : About us : Contact U
Send a comment ?2010 All Seasons Vacation
http://www.weneedavacation.com/Cape/9732.htm 4/9/2010
[' TOWN OF BARNSTABLE
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NO. OF BEDROOMS 5 PRIVATE WELL ORUBLIC WATER
BUILDER OR OWNER b" 15'1 &
DATE PERMIT ISSUED: `� \,\ J 9z
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ✓'
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NO.OF BEDROOMS 3
BUILDER OR OWNER C r1Ad t
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
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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
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THE COMMONWEALTH OF MASSACHUSETTS
__DOAe.R®DOF HEALTH
........................ .....OF...... .............................................
Appliration for Dh4pasal Workii Tonstrnrtion Vernfit
Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian a as-been issued by, the board of health.
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Permit No. .... --7-.�------------------------- Issued .- -----
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THE COMMONWEALTH OF MASSACHUSETTS
/BOARD OF HEALTH
...............................................................
Appliratiun for Biapuoal Works Tonstrurtiun rrmit
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Type of Building Size Lot........2I./(,K}Sq. feet
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Description of Soil `----- ------------------ `'n• --••-- v
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia kas}yeen issued by the board of health.
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Application Approved B
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Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------- --------------------
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Permit No. .....9.~ . ..... ...7----------------------- Issued .-----------�------- Z
- ...... ........
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ ` BOARD OF HEALTH
.......................I.a! ��..... OF ........19A./1 5Ti`'&_A_---------- ------------------------
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V eltifirate of �LII1raylinure
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has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .......... dated --.-..vim..-:-rr. �`.,1�� .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. I
DATE----------------------------(� - i �--....................... Inspector .................. .... : ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............•••P OF.......0/1/7,t/ST0: .ZibY..............................
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PERFORMED BY:JOHN O'DEA,PE-SULWAN ENOINPERn,10
SOIL EVALUATOR NO.2911
.. RRTNESSED BY:DONALD DESMARAYS,R.S.-TOWN OF BARNSTABLE
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Dwelling \, � \ � l q I I + ° \ l / I � \ ` i Side 10'
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it `C- 5 q P �D I L \ 1 FloggedEstuarine Watershed
6 / / / + -1 I / I \ \ \\ , _, by MarioDiGregoric, June, 2011
efieel Area / \\ 4 �- �- X / I i I \ \ \ \ \ t Bordering Vegetated Wetland SEPTIC NOTES
1 \ \ 1 ---/ / f J l "fall \ - \ r t 1.Location of Utilities Shown on This Plan Are Approx.At Least 72 Hours
/ 31,1§5f-Upland / l \ - - -, \ ' Prior to An Excavation For This Project the Contractor Shall Make
V85± Wetland l ` -- -, \ \ \ \ ( I !"R�p� EA / ( Pa bUi \ y
r E I the Required Notification to Dig Safe(1-888-344-7233).
33,3 70f SF to I de \ t pliOVI S M 2.The Contractor is Required to Secure Appropriate Permits From Town
�" ll 1 St W F \ \ \ \ \r'i ( � RIE♦ 5 VF T I \ I I \ Agencies For Construction Defined by This Plan
,- -- _ / / ► Garage
\ 1 ; '(' 1 i \ 1 \ ��� Fod BR A�° - \ ' ( , I _ _ DESIGN DATA Supply. 3.Wherever Sewer Lines Must Cross Water I Limos Both Lines Shall
o -{�} 1 1 I vow i -.� \ ,, 1 I - " - Be Constructed of Class 150 Pressure Pipe and Shall be Water Tested to
`u�acd 1/ •��\ 4 9 1 1 Single Family Assure Watertightness. in General,Water Limes Shall be Constructed
�T\ ` \ -4 Bedroom Q 110 GPD Coordination With COMM Water,and Shall be in Accordance
Shed
l I ` l a,• I No Garbage Grinder With 248 CMR 1.00-7.00&310 CMR 15.00.
tnq i Total Daily Flow=440 GPD 4.A Minimum of 9"of Cover is Required for All Components.
Pad a Use a 1500 Gal Septic Tank S.All Structures Buried Three Feet or More or Subject
P to Vehicular Traffic to be H-20 Loading.It is the Engineer's
LEACHING AREA Recommendation that H-20 Always be used.
6.Install Watertight Risers and Covers to Within 6"of Finished Grade
I -- i \ \ \ l 1 ' ` ` 1 \ Sid GPD/2(8. (+TAR)2=2 0 Required Over Septic Tank Inlet and Ouflet,D-Box,and One Leaching Chamber.
U t Bottom l= a=( . 'x 462'=220 SF 7.Septic System to be Installed in Accordance With 310 CMR 15.00&
en Ge Sr J'RS Bottom Area=(8.5'x 46.5�=395 SF 248 CMR 1.00-7.00 Latest Revision and the Town of Barnstable
a i Ot ft�0 \ o \ \ \ , \ 1 n�l ReStdHit0 FEMA Zone Line as shown on FIRM TotalProvided=615SF Board of Health Regulations.
II Lot 41 \ , \ \ \ ed per5o Carol N Panel # 250001 0015 C (August 19, 1985) LEACHING CHAMBER DESIGN 8•All piping to be Sch.40 PVC.
+ 25.00' \ \ , ` Q�0Itf t el G & 9.D Box Shall Have a Minimum Inside Dimension of 12",and a Minimum
\ \ Mtcha All Pipes to be Schedule 40. Use Sump of 6
5-500 GaL Leaching Chambers in a 10.The Separation Distance Between the Septic Tank Inlets and
8.5'x 46.5'Washed Stone Field as Shown. Outlets Shah be No Less than the Liquid Depth.Inlet Tees Shrill Extend
\ \ a Minimum of 10"Below the Flow Line.Outlet Tees Shall Extend 14"
+ LEVI g&Aaot \ \ ( f / Below the Flow Line,and Shall be Equiped With a Gas Baffle,
+ CB/DH F.G. EL. 58.25 L\ ' See Note 6 (typ.) ` , L•_ k �� �1
F G. EL. 56 - 58 c_-
I Flow Equifizers ddd Cr
EL. 56.7 As Required Finish Grade
Installer To
�H OF confirm Prior EL.
To Any Work SepOcGa�lon 54,75 nk �.L 54.5C.• F5 - 9�Max.
,JOy �� " D-Box 433 s` Compacted Fill FFilter
abric
G� Legend N
!V � _ EL. 54.OQ Leaching 5' > And/Or
o. S Cedar Tree To Be Installea On Chamber - 0 a E co 1 8" - 1 2"
BRB - Road Boun a e ompac ee ase Pea Stone
fO CB H - Concrete ound w drill hole Bedding,"T"s, 314' - 1 1/2"
PISTE
Inspection Port ": a"rtiuiEirittt? en}atiti�: lcie ? LEACHING Double Washed
FS -0 Guy P ?........... Stone
do 8affets :???#ff:tirstiiYiiii .' o31s:#?it#i�?i; ;;a€.`;.i; - ;� CHAMBER
-O Utility Pole as Per Title 5 :;Fv-;Qct ' erekeF:irf'.•:7h : '..:.,.•.: N
OHW- Overhead Wires Deciduous Tree
- °!+?:
:......
- 25- - Elevation Contour 4ZO
{ ! 4 - 10"
$......•••• Underground Utility.Line No Groundwater 8'-s'
r ---•-I
Per Test Hole 9
Wetland Flag
Coniferous Tee DEVELOPED PROFILE OF SYSTEM EL. 34.8 Groundwater CROSS SECTION OF CHAMBER
NOT T6 SCALE Per T.O.B. Standard
NOT TO SCALE
TITLE.' Site Plan PREPARED BY. PREPARED FOR: NOTES:
Proposed Septic Upgrade Sullivan Engineering, Inc. va Sury 1.) The property line information shown was
p Gerry W1111ams, Trustee compiled from available record informatlon. 1•,i
At Po Box 659 7 Parker Road 110 Breeds Hill Road ,#4
0sterville, MA 02655 CSterville'MA 0265 2.) The topographic information was obtained ~
34 Tern L (508)428-3344 (508)428-9617 fox (508) 420-3994 (508) 420-3995 f1 Hyannis, MA 02601 from an on the ground survey performed on
e Lane copesurv&apecod.net or between 01/JUN/11 and 021JUNIll
Bamstable, (Cen terville) Mass, 3.) The datum used is based on the Lake elevation
Draft: JOD Field: WHK/MML 20 0 10 20 40 80 taken from the water level guage at the outlet.
DATE: SCALE rr Review: PS Comp.: WHK/RRL Elevation = 33'-i1» on June 3, 2011 ® 9:00 AM
:
July 8, 2011 1 = 20'
- Project: 31007 Project: C776