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HomeMy WebLinkAbout0079 COUNTY SEAT STREET - Health ` 79 County.Seat Street F Hyannis f= P . A--=291 163 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CO Q 0 Iq Property Address r r-�r_r e e Ve,,- Owner Owner's Name information is �—} Nh�f lej4 �016 O/ required for / State Zip Code Date of Inspection every page. City/Town VA 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: A. General Information I11'I When filling out forms on the computer,use 1. Inspector: , only the tab key to move your )41a Y, O/S e 1// - cursor-do not Name of Inspecto[— _ use the return O _ Tl G H key. �`�l �/ / ) l Company Name „0 �✓o/` Id 99 Company Addrress/ City/Town State Zip Code �0-Y') Telephone umber License Number LU CIQ B.kCertification co - -- 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 CX was performed based on my training and experience in the proper function and maintenance of on site r, rw� sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of u- TitleZ(310 CMR 15.000). The system: �r Passes Conditionally Passes ❑ Fails cnq ❑ Needs Further Evaluation by the Local Approving Authority Inspect s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)rwithin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins-09i08 Title 5 Official Inspection Form:Subsurfac ge Disposal System•?age of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Property Address Owner Owner's Name 0� information is 6 D required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all,of Section D A) System Passes: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): 15ins•09r08 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Property Address L , J ,eeo Owner Owner's Name /� O�6 Q a ^l(7 information is r/ ✓��{K pi i j required for Ci (town State Zip Code Date of Inspection every page. City frown Certification (cont.) 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 ❑ 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. 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 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 3 of V t5ins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `� yr Spa � J Property Address G-re�vi 1 v Owner Owner's Name information is hl�G N required for State Zip Code Date of Inspection every page. City/Town 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 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 ❑ r-,/ Discharge or ponding of effluent to the surface of the ground or surface waters L7 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 uuu than '/z day flow Title 5 official inspection Form:Subsurface Sewage Disposal System•Page<of 17 t5ms•09108 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Okv► Property Address / i'/�l^ Se,.T Owner Owner's Name [�d 6 0 3 a6. /D information is Hh f required for State Zip Code Date of Inspection every page. city/Town 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 cesspoolpr ivy is wi thin 100 feet of a surface water supply or or P Y ❑ tributary to a surface water supply. ❑ �_ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L�' Any portion of a cesspool or privy is.within 50 feet of a private water supply well. ❑ [a/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 20009pd- , 00gpd: El criteria 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 a ❑ 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. Title 5 Official Inspection Form!Subsurface Sewage Disposal system•Page 5 of 17 (Sins•09/08 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rl y 0 CL V1 Property Address f L Owner Owner's Name � La1-6 D 7—� 6`l b information is q 4 i j required for Ci /Town State Zip Code Date of Inspection every page. ty 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? ❑ r,/ 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 �6►� approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 33o DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Tiue 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17 t5ins-09toe Commonwealth of Massachusetts Title 5 official Inspection Form ents Subsurface Sewage Disposal System Form Not for Voluntary Assessor � 9 iolo Property Address Owner Owner's Name Od.60/ —p?h information is /,/�T required for f State Zip Code Date of Inspection every page. City/Town D. System Information Description: al, �0�� �A, opts w -sk. is 4 asx A a w> Pr Number of current residents: Does residence have a garbage grinder? ❑ Yes o Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 2No ❑ Yes ©lao Laundry system inspected? c ❑Seasonal use? Yes No Water meter readings,'if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: 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: t5ins•09/08 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °t 9 Cp t4✓� �+ l ~ Property Address Owner owner's Name Qa 60/ information is Q N 4 U required for State Zip Code Date of Inspection every page. City/town D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons . How was quantity pumped determined? Reason for pumping: Type of stem: 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): tsins•09/08 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 Property AddressL Owner Owner's Name /�ij information is 4 AN✓1�S required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information:-0 W 5 / Were sewage odors detected when arriving at the site? ❑ Yes EJ'No Building Sewer (locate on site plan): (� Depth below grade: feet Material of construction: ❑ cast iron �40 PVC other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): / A Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-OWS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner owners Name / O information is ���!f 'i required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Less- Scum thickness 2 " Distance from top of scum to top of outlet tee or baffle �. Distance from bottom of scum to bottom of outlet tee or baffle �/Q How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7L'✓tte of,, 4 GS /✓� �° Grease Trap (locate on site plan): 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 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page to of 17 t5ins•09(06 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address rcj, L /'P E✓t Owner owner's Name /�/� Qa 6 0/ information is All a vLN(t - Date of Ins ection required for State Zip code p every page. City/Town 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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.): ' Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title s official Inspection Form:Subsurface Sewage Disposal System•Page t f of 17 t5ins•09/08 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �9 C ou Property Address / ee✓l Owner Owner's NarneZ� IV Dd �� information is ANYIIS required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) 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.): A/0 SO l 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 12 of 17 t5ins-MOB Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments � 960 Li W1 Property Address Owner Owner',Name K information is required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Type: leaching pits number: 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.): Q /i Grate a T � r 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 t5ins•OW08 r Commonwealth of Massachusetts. Title 5 Official Inspection Form vimSubsurface Sewage Disposal ystem Form - Not for Voluntary Assessments Property Address Owner owner's Name information is G /f Qa 6 0 required for State Zip Code Date of Inspection every page. Cityrrown ir- D. system Information (cont.) 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.): t&ns•09foo Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �9 (0- Prope y Address Owner owner's Nam4C- T 3_a information is A V1required forState Zip Code Date,of Inspection every page. City/Town 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 pu water supply enters the building. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately /-G 14 /0 a � j nLf 1f3_ t5ins•09r09 Title 5 Official Inspection form:Subsurface sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form /• Not for Voluntary Assessments Property Address/- Owner owner's Name _ information is a A d�C� required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ` 0 /vJ Estimated depth to high ground water: 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: pate ❑ Observed site_(abutting property/observation hole within 150 feet of SAS) 0� Checked with loca[A3oard of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: rC�t"�.Jr Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•OWS Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Volu tary Assessments 1> 9 y Property Address Owner 70wn!s hame information is / '/ (o Q 3—v16,/9 �required for State Zip Code Date of Inspection every page. Town E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked inspection Summary D (System Failure Criteria Applicable to All Systems)completed Ey",System Information — Estimated depth to high groundwater etch of Sewage Disposal System either drawn on page 15 or attached in separate file , i t5ins•OMS Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 N zar ous Materials inventory Sheet Checklist O/oDate : Physical Street Address-Check database to ensure it exists T�Working Phone Number Actual Amounts -( ie. gas being used to.fuel machines,thinner t � clean brushes all count as hazardous materials-no blanks) G�tie� L_.__Storage Information- location of storage, how long is storage for? If none, note that. J_---Disposal Information -iii sere and who?,If none, note that. .. Applicant Signature - understand what is listed and noted -Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? give a vehicle washing policy and explain it . Attach the.Business Certificate with your sign off and comments ventory form should explain what the business consists of and the procedures ping. Notes need to be left to explain what you discussed with them. �► Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: /�,`h� T w BUSINESS LOCATION: 0 r` a` � 0 6dfI NVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: 3- f_4 00 2 CONTACT PERSON: S e!�y/U 4 d L C ' ` EMERGENCY CONTACT TELEPHONE NUMBER: ! 'J MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation:_i_a Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants U Engine and radiator flushes Road Salts (Halite) U Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for-4 years). A business certificate ONLY REGISTERS YOUR NAME in town w you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1" FL.(367h Main Street, Hyannis, MA 02601 (Town Hall) DATE:TO / i✓ j 3 r' ��^' r' APPLICANT'S YOUR NAME/S: c '�/ C G Fill ' please: � �KK Y BUSINESS � 4�c> �. �^ YOUR HOME ADDRESS' .c TELEPHONE # �. s X H me ele hone Number C oL NAME`OF CORPORATION: ' LL V .NAME OF NEW.BUSINESS IS THIS.A HOME OCCUPATIONS YES N0: TYPE OF BUSINESS ADDRESS .OF'BUSINES9 ;ram a e Q MAP/PARCEL;NUMBER - ` __(Assessing): When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnste'ble. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature*'r COMMENTS: 2. BOARD OF HEALTH This individual ha been in' r*gnature** he p r it re ements that pertain to this type of business. Authorized MUST COMPLY WITH ALL COMMENTS: H'AZARDOUS'MATERIALS REGULATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. COMMENTS: Authorized Signature** ° TOWN OF BARNSTABLE t � 6 SEWAGE # a 1b s �Ro LOCATION Cu,. 5 ASSESSOR'S MAP & LOT rMl<( (LLAGE ----,1-1�&PHONE NO. INSTALLER'S NANff ACITY /UUD SEPTIC TANK CA 5oU G CGt� J s .J.=: (type) (size) Z c� LEACHING FAJOMS 3 NO: OF BED'".OR OWNER .� Sc Q 1 C,2 ' BUII, IFTP 7 aJ COMPLIANCE DATE:.., DATE: �; Dom_ J Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist _ within 300 feet of leaching facility) Feet Furnished by S • I r p, b• TOWN OF BARNSTABLE LDCATION SEWAGE # VILLAGE 1'�TC}j Q�`n S ASSESSORS MAP & LOTS /0 f ��1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY MU LEACHING FACILITY: (type (size) NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance-Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leacElng facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished byU T Q� OO o a � cs� A n �:25 r _ r y 1 �j ii a P lD� No. i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for 30igpool OpAem Construction Permit Application for a Permit to Construct(`. )Repair(Upgrade( )Abandon( ) 0 Complete System individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel of l `a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No._ (1-ru i r N ;Le_1493$ �9(saw Type of Building: Dwelling No.of Bedrooms _ Lot Size I4j 3b0 sq.ft. Garbage Grinder(41A Other Type of Building Na nQ No.of.Persons Showers( ITafeteria Other Fixtures UNs u p►T zY E (sTLitEn1 'Z�i N ic'. Lnm x,62_A= Design Flow 3 gallons per day. Calculated daily flow 3 -gallons. Plan Date Lg , 146 1 0,° Number of sheets Revision Date Title s 5 c-A i7p��c�hP Size of Septic Tank 24,61X 1 000 t`.,C;i a Type of S.A.S. r` tJ �a Description of Soil -�M Q�a&N Nature of Repairs or Alterations(Answer when applicable) �FQ� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is Board of Health. Signed Date (�— Application Approved by Date '0 Application Disapproved for the following reasons Permit No. Date Issued (0, 1, ri No. � .�.« ; 'f ° Fee Entered in computer: r THE COMMONWEALTH OF MASSACHUSETTS - J, Yes ' PUBLC HEALTH DIVISION -TOWN-OF BARNSTABLES MASSACHUSETTS 'r l .01pplication for 33iopooal 6potem Congtruction Permit } Application for a Permit to Construct( . )Repair X Upgrade( ):Abandon( ) El Complete System Individual Components Location Address or Lot No. �CA1r 1-\,3 SpcA; S}<' Owner's Name,Address and Tel.No. cc�c,�S CSC CA L LC- Assessor's Map/Parcel ' to 5 (' `jAM G ) Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �APEt� tOt Chi' l-t_.0 SV CS- WTUIr mow, L}ae-y�3 53nt-�gtoto Type of Building: Dwelling No.of Bedrooms_ Lot Size 141;M sq.ft. Garbage Grinder(/1j A Other ° e of Building g AIc)t'>e No.of Persons Showers( O'Cafeteria Other Fixtures t_A,V Arm Q� , I�iT[t�C,J S�r��is } l.['.dsc,r'�s•.�_ . Design.Flow 0)?L)p gallons per day. Calculated daily flow ?SS I S gallons. ' ,k. Plan Date lA t 1 0 Number of sheets Revision Date r-- Title �c�c�t1 e c.���,e QpC_'C'0"r\c- i Size of Septic Tank 2A 6:T_�i T oo c',.tC Type of S.A.S. v 9- _'�QC !QC- C Description of Soil f., -aka takes. 4'SNo4 d Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: ;W The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b -his Board of Health. r— Signed Date 17—2-0 Application Approved by `I Date Application Disapproved for the following reasons Permit'No. ;p11,30 5 DI ( Date Issued (.0 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate-of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired (y,,)Upgraded( ) Abandoned( )by (at' 2i e421'c& 0146✓Dnrf) LL ( at c has been constructed in accordance f with the provisions of Title 5 and the for Disposal System Construction Permit No. �� ,� dated 6�i 7u 1` Installer r1r11 0 LO o�� Designer The issuance of this permit shall not be construed as a guarantee that the sysp wily tion as designed.r Date b d a T Inspector I41* No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mt5poza[ *p.5tem Construction Permit Permission is hereby granted to Construct( ),Repair )Upgrade( )Abandon( ) +� System located at -77 CZ_7,"14,� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construe ion must be completed within three years of the date of h si p Date:__ Approved b D 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only P Y Y PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, C%A�� JM4)y ,hereby certify that the engineered plan signed by me dated to 15 Nlo5 ,concerning the property located at meets all of the, following criteria: • This failed system is connected to a residential dwelling only. There.are.no commercial or business.uses associated with the.dwelling. • The soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests.at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation QQ +adjustment for high G.W. DIFFERENCE BETWEEN A and B , SIGNED : DATE: C NOTICE Based upon the above information;a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc S Town of Barnstable THE rgk�o Regulatory Services Thomas F. Geiler,Director * anxxSTABI e, 9�AMASS. ,0g Public Health Division 1639.rFa�'i° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 6/21/05 Designer: _Shay Environmental Services, Inc. Installer: Capewide Enterprises Address: P.O. Box 627 East Falmouth Address: P.O. Box 763 MA 02536 Marstons Mills, MA 02632 On 6/17/05 Capewide Enterprises was issued a permit to install a (date) (installer) septic system at 79 COUNTY SEAT STREET, HYANNIS, MA based on a design drawn by (address) Shay Environmental Services, Inc. dated 06/15/05 (designer) XX_ I certify that the septic system referenced 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. Y 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. �IH OF Mq CARMEN I staller's Si natu SHAY ra No. 1181 G�STE? (Designer's i nature) (Affix Designer's tamp Here) PLEASE RETURN TO BARNSTABLE 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:Health/Septic/Designer Certification Form Date: 3 //9 / TOWN OF BARNSTABLE TOXIC AND HAZARDOUE . S MATERIALS ON-SITE INVENTORCF-) %, NAME OF BUSINESS: �'P�-) 00 J BUSINESS LOCATION: o Cp&jA' INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: So 9 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: tJ �� _ 0 C7 INFO MATION/REC MENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous,waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum _ Antifreeze (for gasoline or coolant systems) _ _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants tJ Engine and radiator flushes Road Salts (Halite) )�J Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) 0 Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) )0 0 Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED v" O Degreasers for engines and metal Printing ink O Degreasers for driveways &garages Wood preservatives (creosote) 0 Caulk/Grout Swimming pool chlorine O Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes © Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, 120— Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) b Other cleaning solvents ° Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS ��� ���� f �' r ai ,�]V" J s •�: Town of Barnstable- Regulatory Services D�TME Thomas F.Geiler,Director s snaxsTaer.E. Building Division -- - - v MASS Tom Perry,Building Commissioner F 200 Main Street, Hyannis,MA 02601 lc�a+" www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date:3— 0— u b Name: C A-) 17 b cy�_�. Phone#: © © C� Address: `I �f�f 9 SS1 ( �' Village: Name of Business _ [_AJ f 8 Q 4w pl Type of Business: u / W G Map/Lotn INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall beVemployeCustomary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read anbove restrictions for my home occupation I am registeringApplicant: — Date: Homeoc.doc Rev.5/30/03 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and 200 Main Street Offices at the Licensing counter. DATE: C) Fill in please: I . : APPLICANT'S YOUR NAME: S'�6 O L C x 3 BUSINESS YOU HOME ADDRESS: o .31-t 19�e�/ 5 LEPHO E # H me Telephone Number: NAME;OF NEW BUSINESS L TYPE OF BUSINESS IS. THI'S A HOME OCCUPATION? ;Have you been given approval from the building dwision YES NO ADDRESS OF BUSINESS4u�f� S �S ��' MAP/PARCEL NUMBER 0 9/ When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMI TONER'S OFFICE This individ al f�as ee, r ed of any permit requirements that pertain to this type of business. u horiz Signatur COMMENTS: i 2. BOARD OF HEALTH This individual h en i formed of the p r 't requirements that pertain to this type of business. A yffiorized Signature" o COMMENTS: C4 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature" COMMENTS: COMMONWEALTH OF MASSACHUSETTS RECEIVED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS F DEPARTMENT OF ENVIRONMENTAL PROTECTIO orT p 1 2003 " w TOWN OF BARNSTABLE $ HEALTH DEPT. iA N F O / V p�M SVe TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A MAP CERTIFICATION PARCEL, Zo3 i roperty Address: 79 COUNTY SEAT RD. HYANNIS,MA 02601 M291 P163 L5 SOT S 1 wner's Name: BARBARA MCLAUGHLIN — ...- Owner's Address: 79 COUNTY SEAT.RD.HYANNIS,MA 02601 )Date of Inspection: 9/4/03 0 Name of Inspector: (please print) JOHN GRACI,INC. ompany Name: SEPTIC INSPECTIONS OPY Wailing Address: P.O.BOX 2119 TEATICKET,MA.02536 �elephone Number: 508-564-6813 FAX 508-564-7270 ERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is rue,accurate and complete as of the time of the inspection. The inspection was performed based on my training and xperience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system nspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionalltluation esNeeds Furt a by the Local Approving Authority Fails nspector's Signature: Date: 9/4/03 he system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 0 days of completing this inspecti n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the nspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be ent to the system owner and copies sent to the buyer, if applicable,and the approving authority. otes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG HE SYSTEM'S USEFUL LIFE. ***This report only describes conditions at the time of inspection and under the conditions of use at that time.This nspection does not address how the system will perform in the future under the same or different conditions of use. Title S Incnertinn Fnrm 6/1 S/?000 1 i _,t age 2 of LI OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) f roperty Address: 79 COUNTY SEAT RD. HYANNIS,MA 02601 M291 P163 L5 Qwner: BARBARA MCLAUGHLIN ate of Inspection: 9/4/03 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 roR 15.304 exist.Any failure criteria not evaluated are indicated below. mments: �YSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO �ROLONG THE SYSTEM'S USEFUL LIFE. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, pon completion of the replacement or repair,as approved by the Board of Health,will pass. swer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. /a 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 ith 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 hat the tank is less than 20 years old is available. D explain: n/a /a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed ipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of ealth): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced D explain: n/a /a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass nspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed D explain: n/a _ f age 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 COUNTY SEAT RD.HYANNIS,MA 02601 M291 P163 L5 Qwner: BARBARA MCLAUGHLIN ate of Inspection: 9/4/03 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 rotect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. i _ 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) �roperty Address: 79 COUNTY SEAT RD. HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN ate of Inspection: 9/4/03 System Failure Criteria applicable to all systems: ou must indicate"yes"or"no"to each of the following for all-inspections: jYes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped SYSTEM WAS PUMPED IN 1ANUARY OF 2002 PER OWNER. X Any portion of the SAS, cesspool or privy is below high ground water elevation. j X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. T X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. l X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 10 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be ecessary 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. �Iyou must indicate either"yes"or"no"to each of the following: The following criteria apply to large systems in addition to the criteria above) es no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 rider 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. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST rroperty Address: 79 COUNTY SEAT RD.HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN ate of Inspection: 9/4/03 Check if the following have been done. You must indicate "yes"or"no" as to each of the following: ]Yes No Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this 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 `? L - Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance f subsurface sewage disposal systems`? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is nacceptable) [310 CMR 15.302(3)(b)] r ` S Page 6.of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 79 COUNTY SEAT RD.HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN Date of Inspection: 9/4/03 FLOW CONDITIONS ESIDENTIAL umber of bedrooms(design):3 Number of bedrooms(actual): 3 ESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):`16k Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: SYSTEM WAS PUMPED IN JANUARY OF 2002 PER OWNER Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 1800gallons--How was quantity pumped determined?n/a Reason for pumping: MAINTENANCE TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components, date installed(if known)and source of information: 1974 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO (Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 COUNTY SEAT RD. HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN Date of Inspection: 9/4/03 UILDING SEWER(locate on site plan) Pepth below grade: 18" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Pistance from private water supply well or suction line: n/a Pomments(on condition of joints, venting, evidence of leakage, etc.): OWN WATER ASEPTIC TANK: X(locate on site plan) Pepth below grade: 12" aterial of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a f tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10`1 Judge depth: 1" Pistance from top of sludge to bottom of outlet tee or baffle:33" cum thickness: 0" 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: 18" �Iow were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related :o outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a imensions: 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 Date of last pumping: n/a omments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related C outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 COUNTY SEAT RD.HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN Date of Inspection: 9/4/03 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): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NONE SNAKED THROUGH PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a P Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 COUNTY SEAT RD.HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN Date of Inspection: 9/4/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAS 6" OF LEACHING LEFT IN IT. BOTTOM IS AT 8 FT. 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 or no): NO 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 P r - i Q Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 COUNTY SEAT RD.HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN Date of Inspection: 9/4/03 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. w �M M G 0&0- PA u� CA CP N , z in Page l 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 COUNTY SEAT RD.HYANNIS,MA 02601 M291 P163 L5 Owner: BARBARA MCLAUGHLIN Date of Inspection: 9/4/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells 4 Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. i ti " i �r � �� � _ . �� �� � � � . r { [ e. �� �. . - _ { .. � 1 2 � � �� r�� :i � - . ,;� .. _ y SEP-15-2003 13:06 BARNSTABLE WATER COMFP.NY 50S 1790 1313 P.,03r03 _ , . . . . . . . . . . . From Date. . . F MCLAUGHLIN RICHARD Status . . . . Serial Number . Service Address. 104501 ,t � 74 County Seat St Meter Position e ___I Account ID o . . Work Order • • . O Read Mtr Meter UM R R E S Account P Date Po5 Reading Con5wmption L� a T R T ID _ 07/01/03 1 253 1,900 FC 1 N 1 OC153280 _ 04/06/03 1 234 1,600 FC 1 N 1 00153280 _ 01/08/03 1 218 1,700 FC 1 N 1 00153280 10/08/02 1 201 1,700 FC 1 N 1 00153280 _ 07/12/02 1 164 1,500 FC 1 N 1 00153280 _ 04/03/02 1 169 117OO FC 1 N 1 00153290 _ 01/03/02 1 152 21200 FC 1 N 1 00153280 10/09/01 1 130 400 FC 1 N 1 00153280 08/09/01 1 121 1,400 FC 1 1 N 1 00153280 ,O,P,t,:, . ,1,=,R.e.a,d,s. . .6.=,Te,x,t, . ,F,4,=,D,t.l,5, F,A,-D,a,t,e, ,S,e.q. . .F,1,2.=D,i,sp,1,ay T,o,9.9,1,e, , F,2,4,=M,or,e, , . t . TOTAL P.03 7 VENT PIPE (0 Least 24 inches tali) SECTION A -A *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Schedule 40 PVC w/Chorcoal Odor Filter ALL OUTLET PIPES FROM THE A, 10 min. from- \ �A X. fi Existing Foundation �h--se to septic tank Septic tank covers must be CHAMBERcover must be PROFILE VIEW OF LEACHING SYSTEM OfSTRMW-nON 13OX SMALL BE 2' Z X cover must be SET LEVEL FOR AT LEAST 2 FT. --I/-,CONCRETE COVER TOF ELEV 100.00 within 6 in, of finished grade 6" of finished grade within 6 in. of Finished grade % Grade over Septic Tank 99.00 Grade over D-Sox 98.50 ad*ovir SAS ELEVm 97.00 3 5' OUTLET 2', 0 a St 00 f f/s trashed C"Witiod KNOCKOUTS b j. INSPECTION cc 12" INLET-------- ---------------- w/in 6' of fin"r must ` 1 -) S 0.02 t 1.hiad grod. OUTLET HOLE H-10 DIST. BOX S' MaArnum Cover -T of SAS-E(ev,=94.DO Ld 0 10' EXIST. S'0,01 or Greater S- 0.010'.Por foot A 2 Red IN jj EXISTPIPE u') 1,000 GAL. -111011 FROM EXIST, FOUNDATION T`IC TANK 0 15, 4" SCH. 40 Tee-� on SEP 20, Effective Depth a) r- PLAN SECTION CROSS-SECTION 2 s 0 8.5' w/2' stone In betwe CONCRETE FULL FOUNI It H-10 Ki 9�. 4' 2.5' 5 -2�5' CN SYSTEM ,PROFILE 6 in.of 3/4*-1 1/2" 3 HOLE H-10 DISTRIBUTION BOX > compacted stone Effective Length NOT TO SCALE Not to Scale . d. 9 -6 Effective VIdth 3W teeivab 111111116 > 5 .9 S Q) SOIL ABSORPTION SYSTEM (SAS) 5' PROVIDED 6 in.of 3/4"-1 1/2* 0 C H-20 LEACHING UNITS WIGGINS PRECAST GENERAL NOTES compacted stone M Not to Scale NOTE: ALL COMPONENTS MUST HAVE RISERS TO W/IN 6- OF GRADE Bottom of Test Hole I Llev.- 85.00 1. Contractor is responsible for Digsafe notification -------------------------------- and protection of all underground utilities and pipes. Obs. Groundwater Test Hole 1 Elev.= NONE OBSERVED 2. The septic tank and distribution box shall be set level on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sond or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental • Services, Inc. 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan and Local Regulations. 6. If, during installation the contractor encounters any soil conditions or site conditions that are different from those shown on the soil log or in our design LOT, #14 LOT #15 installation must halt & immediate notification be made to Carmen E. Shay - Environmental Services, Inc. LOT #13 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. PERCOLATION TEST 8. Install Tuf-Tite gas baffles or equals on all out tee ends. cG tD 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Date of Percolation Test: JUNE 13, 2005 Test Performed By. Carmen E. Shay, R.S., C.S.E. 110,00 . 10. All solid piping, tees & fittings shall be 4" diameter 7�Ir ......................... Witnessed By. WAIVER (per BARNSTABLE B.O.H) Schedule 40 NSF PVC pipes with water tight joints. EXCAVATOR: Inc. HOLE #1 TEST HOLE #2 Shay EnVironmental Srvcs. TEST 11, Municipal Water is Connected to The Residence and Abutting Percolation Rate: 2 MPI 0 36" ELEV. 97.75 ELEV.= 97. 17.7824 1. Properties Within 150 Feet. t. Test Hole Test Holesl 4 PVCI� THE PROPERTY LINES ARE APPROXIMATE AND No. 1 No. 2 7 25' Vent COMPILED FROM THE SURVEY PLAN GENERATED BY �;-. '. I i WHITNEY & BASSET, LAND SURVEYORS, ENTITLED .-7 i� Faile� DEPTH SOILS ELEV. DEPTH SOILS ELEV. "PLAN OF LAND IN HYANNIS, MA" IN Leach 1PIt I 0 97.75 0 97.00 12, AR • LC 14034-H (Sheet 2), DATED JUNE 1963 Sandy Loom Sandy Loom 1 1 & THE DEED DESCRIPTION ( C171249) �k :J IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 10 YR 3/2 10 YR 3/2 THE SEPTIC SYSTEM INSTALLATION. O.-g. A, 97.001 0.-6. A, 96.50 Sandy Sandy EXISTING LEACH PIT TO :BE PUMPM OUT AND FILLED IN PLACE L oom Loam 2 EXIST-1 GOO GALLON 10 10 YR 5/6 A 5/6 SEPTIC TANK 0 CON 94�75, NOTE: ANY, STRIPPED UT- SbiL CONTAINING LEACHATE 361 6"-o,-,32" Be 94.3,3 ---------- eeJU _7 Medium FROM, THE EXISTING LEACH ..PIT TO BE DISPOSED SandO Sand 0 ASPER BOARD OF HEALTH SPECIFICATIONS, LOT #6 C11) u n T 2.5 Y 7/447 2.5 Y 7/4 DE CK K am Ro 36'- 144' NOW , ARE PRESENT WITHIN 200' OF THE PROPERTY C 144 85.75, 32" C, 8500 LOT #4 ASSESSORS MAP 291 LOT 163 LEGEND EXIS TIN q 3 BEDROO, GARAGE O HOUSE DENOTES PROPOSED PROJECT BENCH MARK F1 04X 11 SPOT GRADE TOP OF FOUNDATION #79 L I I J, - ELEV. 100.00 (Assumed) DENOTES EXISTING X 104.46 SPOT GRADE Perc #1 Al Depth to Perc: 36" to 56" 93 Perc Rate 2 MPI C PL PROPERTY LINE Groundwater Not Observed Y No Observed ESHWT 496p�- PROPOSED CONTOUR ADJUSTED H20 bev. None -94 ASPHALTfi DRIVEWAY - - - - - -97 EXISTING CONTOUR # LOT 5 14,300 Sq�tare Feet -_95 DEEP TEST HOLE & 2-18' DIAM. ACCESS MANHOLES PERCOLATION TEST LOCATION Lt .= 6 FOOT STOCKADE FENCE 17 62' . 431 96 --------------- INLET J OUTLET CD PLOT P LAN THE ACCESS COVERS FOR THE SEPTIC TANK, D SET DEEPER THAN 6 INCHES BELOW FINISHED OF PROPOSED SEPTIC SYSTEM UPGRADE ISTRIBUTION BOX AND LEACHING COMPONENT 'GRADE SHALL BE RAISED TO WITHIN 6* OF STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE, PREPARED FOR ISY PLAN VIEW I NSTALL TIUF-TITE GAS BAFFLES OR EQUALS (40 FOOT is- 77/::e RIGHT O� M R . DOSE CABLE 3-24' REMOVABLE COVERS AT 4 #79 COU NTY SEAT STREET 7 3*-mln. clearance ... ! 11 13' NLET'r:,I 8* W1n.T J2 INLET--e�.11, in. Inlet to outlet It'min. 1 t�' HYANNIS , MA OUTLET Design Calculation 5' -7- -7- PREPARED BY:4'_O* F Number of Bedrooms: 3 Equivalent to 530 Gcl./Day (330 Gol,/Day Min, per Title V) am iii LiquIn id depthCv Garbage Grinder: No Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title'V) C N rdRHEY E. SHA Y Gal. 660 USE EXIST 1,000 GAL Septic Tank, 0 20 40 50 0 Septic Tank 2 x 330 G L) S ENVIRONMENTAL SERVICES, INC. 0. 1 � - 1 0 SOIL ABSORP11ON AREA: Using percolation rate of <2 rnin.�inch , ' I I 1 11 -0" No CROSS SECTION END SECT ECTION Bottom Area: 0.74 gal/sq. ft. x 290sq. ft. = 214.150 gollor�'s P.O. BOX 627 Side all Area; 0.74 gal./sq. ft. x 156 sq, ft. = 115.40 gallons G1 STr- EAST FALMOUTH, MA 02536 Providing: = 330.00 gallons TYPICAL 1000 GALLON SEPTIC TAN •K Use: (2) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE I DEPTH, SCALE: 1 "=20" S141VITAIR TEL/FAX 508-539-7966 NOT TO SCALE SCALE: 1 "=20' DRAWN BY: CES DATE: JUNE 13, 2005 TO BE USED WITH 2.5' OF WASHED STONE ON THE, SIDES AND I cover INS w/i- '"A"C"""PEC ON toff n 67 0, finis, Odor r. O`;LET�T FE, T,-Tt, of A U t� '1 8 /L nit 5' s U71 4 5' 2�5 10, 17.00 , 4 4' OF WASHED STONE ON THE ENDS & 2' IN-BETWEEN CHAMBERS.. PROJECT#SD761 FILENAME: SD761PP.DWG S H EET 1 , OF 1 -T