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0056 WEDGEWOOD DRIVE - Health
56 Wedgewood Drive Centeiville A= 189 - 141 S►ua •� UPC 12534 No.2.153L +tom �r 1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary AssesFts opy 56 Wedgewood Drive ` Property Address Henrique Neves Owner Owner's Name. / information is required for every Centerville V MA 02632 March 11 2021 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 fillingng outA. Inspector Information 51+It- IS 0a 3 out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Co - m Company Address Forestdale MA 02644 Cityrrown State Zip Code 508-888-6055 S112843 Telephone Number License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. Passes 2. 8 Conditionally Passes 3. Needs Further Evaluation by the Local Approving Authority 4. Fails March 15. 2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. CityfTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2 stem Conditionally Sy 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" 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 exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced wit a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection f it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is I s than 20 years old is available. El ❑ N ❑ ND xplain below): 15insp.doc-rev.M6=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is Centerville MA 02632 March 11 2021 required for every , page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break ut or high static water level in the distribution box due to broken or obstructed pipe(s) or due a broken, settled or uneven distribution box. System will pass inspection if(with approval of B rd of Health): ❑ broken pipe(s)are replac ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is I eled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more thaR4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with appro�al of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i" r l 3) Further Evaluation is Requir d by the Board of Health: ❑ Conditions exist which r uire further evaluation by the Board of Health in order to determine if the system is failing to rotect public health, safety or the environment. a. System will pass nless 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owners Name information is required for every Centerville MA 02632 March 11, 2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Healt�(and Public Water Supplier, if any) determines that the system is functioning ' a manner that protects the public health, safety and environment: / ❑ The system has a septic tank and soil a sorption system (SAS)and the SAS is within 100 feet of a surface water supply or tribut ry 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 AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply we **. Method used to determine distance* **This system passes if the well wa r analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided th no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 C.4. Yes No ❑ ❑ the syst/withfeet of a surface drinking water supply ❑ ❑ the syst feet of a tributary to a surface drinking water supply ❑ ❑ the systa nitrogen sensitive area (Interim Wellhead Protection Area—Ied Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.71262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IF'o 56 Wedgewood Drive Property Address Henrique Neves Owner Owners Name information is Centerville MA 02632 March 11 2021 required for every , page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 612 GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2019=230 GPD 2020= 112 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: February 2021Date t5insp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): , Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to th Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No pumping records found since 2014 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance and heavy solids. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ua � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrigue Neves Owner Owner's Name information is Centerville MA 02632 March 11 2021 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: Septic tank installed approx 1973. D-box and leach system installed 11/06/2014. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts UO Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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: 8.5'x 4.5'x 5' 1000 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 12" inlet, 5"at outlet. Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 17" (Filter in outlet tee) How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet concrete baffle and outlet pvc tee in place. Liquid level at outlet invert. Risers bring inlet cover within 6"of grade and outlet to grade. Filter in outlet tee needs to be cleaned every year. Tank pumped and cleaned after inspection by Ready Rooter, Inc. Recommend maintenance pumping every two years with full time use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owners Name information isequired or every Centerville MA 02632 March 11, 2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑/erglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to/ottom or baffle Distance from bottom of scuutlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal fiberglass El polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is Centerville MA 02632 March 11 2021 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float sw'ches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, four outlets, speed levelers in place. Solids carryover present, removed during inspection. No high water stainig over outlet inverts. H-20 DB-5, 3' below grade. Riser brings cover within 6"of grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 9 Commonwealth of Massachusetts r - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 28-Infiltrator HiCap ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owners Name information formation is required for every Centerville MA 02632 March 11, 2021 page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4 rows of 7 H-20 units 3.5' below grade. No standing liquid in inspection port. Light staining 3"up inspection port sump. No sign of past hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts u p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 56 Wedgewood Drive ,p."�-- — Property Address Henrigue Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, sign f hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrique Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Cityfrown State Zip Code Date of Ins pection D. System Information (cont.) 14. 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 f r 1 i l fl , v AY ��' 3 - t5insp.doc-rev.7/2 M16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrigue Neves Owner Owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: '5 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: 10/24/2014 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: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole in 2014 found no ground water at 132"(elv= 37.7). Base of units at elv=43.6 per engineered plans. No high ground water in area of system Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 � 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Wedgewood Drive Property Address Henrigue Neves Owner owner's Name information is required for every Centerville MA 02632 March 11, 2021 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: i 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 . s Town of Barnstable °FtHE T � Regulatory Services yP °� Richard V. Scali, Interim Director BARNSTABLE.A Public Health Division 9 MASS. 0 `bATF p y,�a Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 ' Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Svstems Property Address: la \,J�-Ct 1 ��"� Assessor's Map\Parcel: n L Lt Property Owners Name: H GN�-A Q LLe— I)rr-VF C, In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an "x" in the applicable box next to each line certifying the information. Yes N\A- Imo' ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter) ❑ I have been provided with the Owner's Manual ❑ I have been provided with the Operation and Maintenance Manual ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the Approval ❑ I�For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) I� ❑ If the design does not provide for the use of garbage grinders, the restriction is understood — / and accepted IQ' ❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 I , 4� - '✓ agree to comply with all terms and conditions above. Prop ners printed name C&W-2:eo- fty Zust Signature Date Note: This form be submitted along with the septic system disposal works permit application for all I\A systems including new construction, rep airs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\IA homeowner certitication.doc No. / 491� Fee_I D� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 1 01ptlYicatioii for Disposal 6pstriii Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(-�Abandon( ) []Complete System E21ndividual Components Location Address or Lot Nos C>�e�5� �P Owner's Name,Address,and Tel.No. Sig-171- S7Ga S-C it-. Assessor's Map/Parcel k sn 4 1,4 1C, A <aQ6-3 Installer's Name,Address,and Tel.No. Scf�?-'FW-EZ>SS Designer's Name,Address,and Tel.No. Sig 36::�-33 I( © . Uo S Type of Building: Dwelling No.of Bedrooms Lot Size �Z 3-7 sq.ft. Garbage Grinder( ) Other Type of Building S. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 4� '3 gpd Plan Date ©c`. ��Q �-� Number of sheets Revision Date Title Size of Septic Tank s� Type of S.A.S. VW�CAx,_Lc.+�� Description of Soil Z:::, 4—_, Natutrte of Repairs or Alterations(Answer when applicable)1,,,� ,,d�l =�n �� IC �(�a1,,t-�,�,_.0 J-- t"�._1 L ,ra�Ai.� ���� �.. C .�aC��, ��,..o,� r.+-� �'BC� r rCiNy� C!, i- 5ec)e,." Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ign do Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued ti UI 112- No. 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 1 2pplication for -isposal *pstetn Construction Vertu Application for a Permit to Construct( ) Repair( ) Upgrade(�bandon( ) ❑Complete System k21ndividual Components Location Address or Lot No Jr-C Owner's Name,Address,and Tel.No, Assessor's Map/Parcel Installer's Name,Address,and Tel.No. b S Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size 3-7 sq.ft. Garbage Grinder( ) Other Type of Building ;a C No.of Persons Showers( ) Cafeteria( ) -Other Fixtures Design Flow(min.required) S_'5O gpd Design flow provided �, �' gpd Plan Date Q�\ O Number of sheets c>� Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil { Nature of Repairs or Alterations(Answer when applicable)1 ,�,, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ign d s Date Application Approved by Date Application Disapproved by Date for the following reasons 41, Permit No. "y Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(V-%- Abandoned( )by -c d �ti c���1-- ^ cSq at has been constructed in ac 0jnA with the provisions of Title 5 and the for Disposal System Construction Permit No Gtdd Installers� �,��-5- ��e �,`� Designer r #bedrooms Approved design flow gpd The issuance o 17er its all not be construed as a guarantee that the system w'r ton d 'gn d. / v� Date Inspector � ' " v� No. r- ------------------------------------------------------------------------------------------------------------- ' � Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade(� Abandon( /� System located at S- C_2_ r - ; u-<_- J / and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with p Y Title 5 and the following local provisions or special conditions. Provided:Con ructio mu 1 be completed within three years of the date of this permit. Date Approved by Town of Barnstable �oFt ' ti Regulatory Services o� Richard V. Scali,Interim Director * HAMSrABLE, 9� MASS. `�� Public Health Division ATEOMP'ta Thomas McKean,Director ' 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form 4 a Date: ti' V"l Sewage Permit#a::::k� - ,C) Assessor's Map\Parcel '� l 1� Designer: u Installer: - �r Address: 0_�60)6 Address: On ff was issued a permit to install a (date) (installer) ----I septic system at o based on a design drawn by ( dress) tt� . . dated (designer)Dvfelv\- X I certify that the septic system referenbed above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters (if applicable) J o" ARR (Installer's Signature) R o: U1z -" ' 011 q�c/ST Eo (Designer's Signature) SAN1 ARa� PLEASE RETURN TO BALSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc / l_TOWN OF BARNSTABLE � 6 lOCATION S �AJs✓UGc 2 V=�oc-tr q zr, GE# VILLAGE C rt \ —Z ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(typerr ��3.a�at- ', NO.OF BEDROOMS OWNER PERMIT DATE: 3 COMPLIANCE DATE: L Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > S_ 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 1 i `o 1 _ -_ veal via Town of Barnstable P# Department of Regulatory Services t�arternerrE Public Health Division Date. b� 290 Main Street,Hyannis MA 02601 Ay lEU pA1'1� r^ - Date Scheduled Time Fee:Pd. Sail Suitability Assessment for Se Performed By: ✓ t(j� Witnessed By: LOCATION& GENERAL INFORMATION Location Address Owner's Name c �, 5 �J�-�je:I� 0t-, 1 crrt Z �� V C� V Address Assessor's Map/Parcel: 1 �� ( Engineer's Name NEW CONSTRUCTION REPAIR Telephone# j o?_ ;c—Q Land Use s 1Y 1�A''l.. Slopes(%) d Z _ `Surface Stones _ Distances from: Open Water Body ' _00ft Possible Wet Area �ft Drinking Water Well �! SV ft Drainage Way } ZaU ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) X : 1 ;93 :;7..?t� "J Parent material(geologic) azy av�s 11 Depth to Bedrock A/ 4— Depth to Groundwater. Standing Water in Hole: N Weeping from Pit Face ti t Estimated Seasonal High Groundwater N f DETE NIINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observi d s nding in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level �_ Adj.factor'— Adj.Groundwater Navel,, PERCOLATION TESL' bete- Time Observation ? Hole# J Time at h" /I" Depth of Perc sy _ Time at 6" , Start Pre-soak Time @ In to 'Tom— 0� 'Time(91'4' End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(`f'/N) Original: Pubic Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEE,FOBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,96 Gravel) Al 2. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten %Gravel) OH r t)PrM.ti OtY1 b R 3/ ,-" DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color 'Soil Other Surface(in.) (USDA) (Munsell) Mottling' (Structure,Stones,Boulders. Consistency.%Gravel) ` A- 3 Allp `, e f 6l8 32- 2 C . 2y 0Iq DEEP OBSERVATION HOLE LOG Hole# � Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. l Consistency, ro A 33�t f 12� and 2 l Flood Insurance Rate Map: / Above 500 year flood boundary No— Yes Within 500 year boundary No V► Yes Within 100 year flood boundary No Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? N149 S If not,what is the depth of naturally occurring pervious material? Certification I certify that on 9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required t i ,expertise and experience described in 310 CMR 15.017. Signature Date �� 30. /� Q:ISEPTICIPERCPORM.DOC Commonwealth of Massachusetts Title�6 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification �,�,� Important: When filling out 1. Property Information: forms on the computer, use 56 Wedgewood Drive - Centerville, MA only the tab key Property Address to move your Walter and Mary Zidziunas cursor-do not use the return Owner's Name key. c% Ray Zinnas— 1868 Dartford Road Owner's Address Bethlehem PA 18015 City/Town State Zip Code Date of Inspection: September 10, 2005Date 2. Inspector: i David D. Coughanowr, R.S. Name of Inspector Eco-Tech Environmental Company Name 43 Triangle Circle cn Company Address Sandwich MA '`02563 = ,1 City/Town State Zip Code �- 508 364 0894 { Telephone Number W m Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority s September 10, 2005 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under t5-2184.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name 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. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM A. Certification (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5-2184.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name 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 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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. t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6of17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM B. Checklist 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 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 ® ❑ 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? ❑ N/A 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, including 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(3)(b)] t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7of17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 2 I Does residence have a garbage grinder? Removal of grinder is recommended ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 97 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: 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, diribufiera lie*, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age unknown—system is assumed to have been installed at time of dwelling's construction in 1973 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form L1M C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): 1 Depth below grade: 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 ❑ Yes ❑ No certificate) Dimensions: S.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 inches Distance from top of sludge to bottom of outlet tee or baffle 30 inches Scum thickness 1 inch Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? Probe to top of tank t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Traplocate on site plan): ( P ) Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2184.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iL^M Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 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 evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2184.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to contain 46 inches of effluent in a 6 foot precast leaching pit. No staining at cover interface or in overlying soils t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'LAM C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2184.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 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. LOCATIONS LEACH A B O PIT 1 9.5 It 43.5 It 2 1 1 ft 45 It 3 22.5 It 48 It 2 SEPTIC a TANK o A g EXISTING DWELLING w # 56 z w I— WEDGEWOOD DRIVE NOT TO SCALE t5-2184.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 56 Wedgewood Drive Property Address Centerville MA 02632 City/Town State Zip Code Walter and Mary Zidziunas September 10, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 30+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Barnstable GIS Department files ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 30 feet above groundwater table. t5-2184.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 17 r THIS PAGE IS INTENTIONALLY LEFT BL ANK t5-2184.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 17 of 17 q ,I TOWN OF BARNSTABLE LOCATION 6 V" �� br SEWAGE # S VILLAGE �4fe r V r �� ASSESSOR'S MAP & LOT � r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type)_Q (size) (0D© NO.OF BEDROOMS 3 A BUILDER OR OWNER WA f IL cl t`q r-/ Z i Z i V k qS PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: i � Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) . Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Cc o ''i'EC H E N V t R O Nt M L NTA-L (tt)S p) r LOCATIONS LEACH A B j. i 3 1 9.5 ft 43.5 Ft 4 2 1 1 ft 45 ft 2 3 22.5 ft 48 ft , SEPTIC TANK A B " EXISTING DWELLING �I w # 56 W k { I WEDGEWOOD DRIVE NOT TO SCALE CENTERVILLE `I LEGEND FOOTPRINT FOR CONVENTIONAL 1- PROPOSED CONTOUR ROSE 28 0 5 BEDROOM LEACHING\ �N CH M q — 98 PROPOSED SPOT GRADE /� c 0 / D cisn��M — 98 -- EXISTING CONTOUR SITEWFo� o m a ELEVATION 0 aR o 48.84 �`� + 96.52 EXISTING SPOT GRADE Q b ' SPo o / " TON CONG� W— EXISTING WATER SERVICE 50, 146 TEST PIT �NgOW DR• � ent I�` 43.75' \\ I 4 49BUMps R I? 0,40 12 ft O/\II EXIST. 1,060 LEACH PIT �� LOCUS MAP o Tp-3 �% EXIST. 1,000G\ '� _ --50 0 / SEPTIC TANK C) �� I " LOT 5 ' AREA = Esf ; SEPTIC SYSTEM PLAN BOOK 243 PA PAGE 69 �� I, 'SSR MAP189 PCL 141 4. REPAIR PLAN J� G` LOCATED AT: 56 WEDGEWOOD DRIVE r,SJ r 1\ CEN TER VI LLE, MA GENERAL NOTES: PREPARED FOR ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL READY ROOTER EXC. BOARD OF HEALTH AND THE DESIGN ENGINEER. 4\, CV 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL 0 CMR 1405 5.' REGULATIONS. EXCEPT AS REQUESTED BELOW: OCTOBER 29, 2014 1) A 0.29 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING ,W TO BE 3.29 FT (MAX) BELOW GRADE VS REO'D 3 Fr. (VENT PROVIDED) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR ��� OF L� \ TO ENGINEER D APPROVAL BY THE BOARD OF HEALTH AND THE 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING DARKEN ✓�, FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN MYR � f� F ENGINEER BEFORE CONSTRUCTION CONTINUES. ( n,_ ji �\40 v, 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OFG� E O THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF FAT Q �Q^ HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. SgNITA���'� O 7. DWELLING IS SERVICED BY MUNICIPAL WATER SUPPLY. Of 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 6 1 � TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. s�. 00 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 99^ \ 48 LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO STARTING WORK. MEYER C�(.. SONS INC. 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION P. O. Box 9 81 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY E. SANDWICH , M A 02537 D f 13. NO KNOWN PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING / 14. ALL PIPING TO BE 4' SCH 40 ® 1/8-/FT (UNLESS SPEC. ) PH. (508)360-3311 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW P A t FOR THE USE OF A GARBAGE GRINDER. fax (774)413-9468 . 16. NO WETLANDS WITHIN 150 FT. OF PROPOSED LEACHING meyerandsonstitie5@gmaii.com SCALE: 1 in = 20 ft a SHEET 1 OF 2 J#1644 F NOTE: TO PREVENT BREAKOUT, THE PROPOSED DESIGN CRITERIA **PROPERTY IS IN ESTUARIES PROT. ZONE** NOTE: MAGNETIC TAPE TO,BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:72.02 *NO PROPOSED INCREASE IN FLOW* FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. NUMBER OF BEDROOMS: EXISTING 5 BEDROOM DWELLING TOR EL.=49.45t SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 550 G.P.D. OUTLET AND SET TO 6' OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. VENT • F.G. EL.=48.50t F.G. EL.=48.50f F.G. EL: 48.50t F.G. EL: 48.40(MAX.) GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) SEPTIC TANK: USE EXISTING 1,000 GALLON SEPTIC TANK 9" MIN COVER/ y LEACHING AREA REQUIRED: (550)/0.74 = 743.24 S.F. 36" MAX COVER L = 25' L = 15'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) DISTRIBUTION BOX: 5 OUTLETS (MINIMUM) ® S=1% (MIN.) EL. = 46.50 0 S=1% (MIN.) 0 S=1% (MIN.) TO WITHIN 3" OF FINISH GRADE 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC PRIMARY S.A.S. t0• 14• 6 11" TO USE 4 ROWS OF 7 - INFILTRATOR HI-CAPACITY H-20 UNITS-NO STONE 48" LIQUID INVERT .45 LEVEL INV.=45.25 INV.=44.70 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF BIODIFFUSER) r* GAS BAFFLE) PROPOSED 4 ROWS OF 7 UNITS AT 6.25'/UNIT = 43.75'/ROW D-BOX INV.=44.80 (BIODIFFUSERS) 28 UNITS x 6.25 LF x 4.73 SF/LF = 827.75 SF INV.=45.00 46=5 SOIL ABSORPTION SYSTEM (PROFILE) ) TOTAL AREA = 827.75 SF EXIST. 1.000 GALLON SEPTIC TANK DESIGN FLOW PROVIDED: 0.74GPD/SF(827.75SF)= 612.53 GPD > 550 GPD req'd `? 1INV.=45 SEWER OUTLET RESTORE VEGETATIVE COVER BACKFILL WITH CLEAN PERC SAND 75- TO TOP OF CHAMBERS :1 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING BREAKOUT=TOP ELEV.=45.1 1 INV. ELEV.=44.70 PIPE INVERTS PRIOR TO CONSTRUCTION 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=43.62 EXISTING SUITABLE GRADE ON A MECHANICALLY COMPACTED SIX 2.83 MATERIAL INCH CRUSHED STONE BASE, AS SPECIFIED IN 5' MIN. ABOVE BOTTOM OF 310 CMR 15.221(2) T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' =11.3; 3) REPLACE EXISTING 1.000 GALLON SEPTIC TANK (6.12' PROVIDED) USE 4 ROWS OF 7-HIGH CAPACITY WITH 1500 GALLON SEPTIC TANK IF FAILED, BOTTOM OF TESTHOLE EL.=37.50 _ INFILTRATOR UNITS (1-120) - NO STONE DAMAGED, OR UNDERSIZED. 4) INSTALL INLET & OUTLET TEES W/ • GAS BAFFLE AS REQUIRED SEPTIC SYSTEM PROFILE TYPICAL SECTION 1s" N.T.S N.T.S. SOIL LOG P#:14539 SOILE EVALUATOR: DARRENRM? MEYER4 IRS CSE#1614 24, 201 �� OF Mgs� INVERT -j y SECTION HEIGHT END CAP WITNESS: DONNA MIORANDI, BARNSTABLE HEALTH DEPT. o� D�,R EN40 N 1 L INFILTRATOR - HI CAPACITY (H2O) CHAMBER Elev. TP 1 Depth Elev. TP-2 Depth Elev. TP-3 Depth Elev. TP-4 Depth MODEL 16" HICAP . 1140 SAND LENGTH 76" 48.50 0" 48.50 LOAMY SANG 48.50 0" 48.70 A LOAMY SAND 0" 48.60 A LOAMY 0" O NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT A LOAMY SAND � 48.00 10YR 3/1 6" 48.00 10YR 3/1 6„ 48 28 10YR 3/1 5" 48.18 10YR 3/1 5„ SOITAO EFFECTIVE LENGTH 75" To CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY B LOAMY SAND B B B DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LOAMY SAND LOAMY SAND LOAMY SAND 10YR 6/8 10YR 6/8 10YR 6/8 10YR 6/8 to l� SIDE WALL HEIGHT 11" 45.59 C 35" 45.50 C 36" 46.02 C 32" 45.85 C 33" l OVERALL HEIGHT 16" PERC TEST' OVERALL WIDTH 34" 4640 TRUEMAN BLVD ® 44.3 MEDIUM SAND PERC CAPACITY 13.6 CIFs HILLIARD, OH/0 43026 2.SY 6/4 MEDIUM SAND 0 44.45 MEDIUM SAND MEDIUM SAND (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. 2.5Y 6/4 2.5Y 6/4 2.5Y 6/4 1 PROPOSED SEPTIC SYSTEM/SITE PLAN 37.50 132" 37.50 132" 37.70 132" 37.60 132" 56 WEDGEWOOD DRIVE, CENTERVILLE, MA PERC RATE: <2 MIN/IN. SOILS IN ("C' HORIZON) PERC RATE: <2 MIN/IN. SOILS IN ("C' HORIZON) I Prepared for: Ready Rooter NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED I System Design and Site Pion by: SCALE DRAWN DATE: Meyer&Sons,Inc. NTS D.M.M. 10/29/14 • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX 981 to conduct soil evaluations and that the above analysis has been y CHECKED SHEET NO. y performed b me consistent with the ,. EAST SANDWICH,MA 02537 requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Evol. Exam in October, 1999. 508-362-2922 D.M.M. 2 Of 2