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HomeMy WebLinkAbout0061 LINDA LANE - Health 61 Linda-Lane Hyannis. CP A 222 a„a r� 4 e M Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments s 61 LINDA LN Property Address SPRAGUE Owner information is Owner's Name '" required for ---CENT€ LE 'f"�( (n� MA 02632 7/2/12 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this farm. Inspection forms may not.be altered In any way. Please see completeness checklist at the end of the form. tmp°rta`d` When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-'do riot — use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State 508-420-4534 S14297 Zip Code Telephone Number License Number B. Certif cation -- _- - - -- 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 / 7/2/12 In ctor�ignatLre Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health'or DEP)within 30 days of completing this inspection. If the'system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "'""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Lmd Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .•`''� 61 LINDA LN Property Address SPRAGUE Owner information is Owner's Name required for CENTERVILLE MA . - 02632 7/2/12 every page. City/Town � B. Certification (cont.) State Zip Code 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: NO OBSERVATION PORTS WERE FOUND ON THE SAS, INSP WAS BASED ON D-BOX NO SIGNS OF FAILURE WERE FOUND. HOUSE HAS BEEN USED SEASONALLY. FUTURE PERFORMANCE OF SYSTEM CAN NOT BE PREDICTED UNDER THE SAME OR INCREASED USE B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be (eplaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration`or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 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- No t of for Voluntary Assessments 61 LINDA LN _ Property Address SPRAGUE Owner Owner's Name information is required for CENTERVILLE MA. 02632 7/2/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): Observation of sewage backup or break aut rir.h'igh 9tati`c W8t'e-r 6V6I in the diStributi m bax 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 rentovetl 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information is CENTERVILLE required for MA 02632 _ 7/2/12 every page. Cdyrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, 'safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form }�J Subsurface Sewage Disp osal posal System Form-Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner information is Owner's Name required for CENTERVILLE MA 02632 7/2/12 every page. City town State ZipCode Date of Inspection B. Certification (cont.) Yes No Required Pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion'of a cesspool or privy is within a Zone 1 of a public well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes iif`th well water AhAl lb, Wf6 in6d at a D P bertifled 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.] r❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of'the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well I 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. ts;ns•os�os Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Y Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information is required for CENTERVILLE MA 02632 7/2/12 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system'received normal flows,in the previous two week period? a volumes❑ Have large A 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 faciIity'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? EJ Were the septid'tan'k'manholes runcovered, -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)] M' System Information Residential Flow Conditions: vum'Der of bedrooms(design): 4 "I --�-_-_c�_r_ i__a.._n. 4 FNUI I IUCI VI UCUI oomi is (C-RAUGl J. DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal 9 p al System Form Not for Voluntary Assessments 61 LINDA LN Properly Address SPRAGUE Owner Owner's Name information is rernuirerf•fnr CENTERVILLE every page. Cityrrown MA 02632 ­ 7/2/12 State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A PLASTIC 1500 GALLON TANK D- BOX AND A 4 BEDROOM SAS OF INFILTRATORS Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry.system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail 2010------267 2011-------303 HOUSE DOES HAVE IRRIGATION SYSTEM Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: design flow(based on 3-f 6 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: %ins a 09/08 Title"5 Officiallnspection Form:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System y m Form -Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information.is for fP CENTERVILLE l.71_IIfPFt . every page. CWr own MA 02632,__ 7/2/12. State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date V�tICI kUGJl.11VG UCIVVV). General Information Pumping Records: Source of information: PUMPED IN 2010 ACCORDING TO OWNER Was system pumped as part of the inspection? El Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system- El Single cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•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 System Disposal S P y em Form -Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information is raaiq. for, CENTERVILLE MA 02632.�, .. every page. City/Town 7/2/12State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: 1998 OFF AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): uCNu i uciuw yl 8uc. feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): uwLdi II:C 11 un 1 Ni ivdLI wBiGi auNNiy wCu ui auuwi i w IC. feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ® polyethylene ❑ other(explain) POLY TANK IRRIGATION LINE GOES RIGHT OVER OUTLET COVER RE LOCATING LINE FOR EASIER ACCESS 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: VARYING LIGHT f,5iiis�Os7o8 Title 5 Officiarinspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b1 Subsurface Sewage Disposal System p y tam Form- Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information is required for CENTERVILLE 02632,E, every page. City/Town MA_ 7/2/12State Zip Code Date of Inspection D. System Information (cont.) . Septic Tank(cont.) UlStdl IUU fl UIII LUG.!Uf JIU U V IJUI UIII UI IJUL L lCC UI bdlllC Scum thickness TRACE AMOUNTS CLUMPING Distance from top of scum to top of outlet tee or baffle hJIJtG1111:C II UI I I UUllUl l l I SlilJl l l tU IJUIIUI I I Uf UL LIM MU Ur Lial I I& L_m How were dimensions determined? WOODEN POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PLASTIC TANK OUTLET COVER HAS IRRIGATION LINE GOING RIGHT OVER IT RE-LOCATING IT.COVERS WERE INDENTED TYPICAL OF EARLIER PLASTIC COVERS BRINGING THEM CLOSER TO GRADE WITH NEW HEAVIER COVERS AND RISERS Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal _9 p al System Form Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information is required for CENTERVILLE every page. Cityrrown MA 02632 .. 7/2/12 State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 t5ins•09= Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i KN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Y m Form -Not for Voluntary Assessments ' 61 LINDA LN Property Address SPRAGUE Owner Name information is Owner's required for CENTERVILLE MA 02632_r 7/2/12 every page. Cityrrown State ZipCode Date of Inspection D. System Information (Cont.) Distribution Box (if present must be opened) (locate on site plan): IIUI Q JIICLIILi 010I I 1 ICVCUUVCU IYC 0.1 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.): BOX LEVEL NO SIGNS OF BACK UP OR FAILURE AT TIME OF INSPECTION Pump Chamber(locate on site plan): Pumps in working order: ❑ No Yes 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: NO OBSERVATION PORTS FOUND ALSO NO TIES ON AS-BUILT CARD t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Y Not for Voluntary Assessments 01 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information is required for CENTERVILLE MA..,.., 02632 . 7/2/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: Li Icaul lu ly Nlta iliilit`ticr: ® leaching chambers number: 5 INFILTRATORS ❑ leaching galleries number: nr__._i:__•___:_-.__ Li 1eacI III Ky tl a It;l ICJ I iu I IUCI', ICI Il�yll ❑ leaching fields number, dimensions: ❑ overflow cesspool number: LJ 7itiiuv8uv WWI,Glllativc ayatt:nl Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO OBSERVATION PORTS OR TIES ON AS-BUILT CARD WE WERE NOT ABLE TO LOCATE SAS TO DETERMINE LEVEL OF LIQUID OR STAIN LINES BECAUSE OF THIS 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 bins:09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form System.ICJ Subsurface Sewage Disposal S p y m Form -Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Owner's Name information is rentured fnr CENTERVILLE MA 02632 7/2/12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (Cont.--_____ Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Volunt ary Assessments 61 LINDA LN ' Property Address SPRAGUE Owner Owner's Name information is reg CENTERVILLE Lyred fnr MA 02632 7/2/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form l�) Subsurface Sewage Disposal 9 p al System Form -Not for Voluntary Assessments 61 LINDA LN Property Address SPRAGUE Owner Name information is Owner's re,mired for CENTERVILLE every page MA 02632, , 7/2/12. City/Town State ZipCode Date of Inspection D. System Information (cont.) Site Exam: Ipl 1�11C1:1\JIUIJC ® Surface water ® Check cellar Id JI IQIIVw We11D Estimated depth to high ground water: 5+ feet Please indicate all methods used to determine the high ground water elevation: r1 U vuLlta,:i I;C_.UJ rI I UI1�1 syJ-1lC1-1 Jams.I:g plaL : .s on r ecoo d If checked, date of design plan reviewed: Date ❑ Observed site abu( tting property/observation hole within 150 feet of SAS) 17-1 trl ICI;RCU WIU I IUl:dl DUttl U tJI Neal�I -exp a: I: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database=explain: You must describe how you established the high groundwater elevation: 1995 CODE I Before filing this Inspection Report, please see Report Completeness Checklist on next-page. t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments st y61 LINDA LN M Property Address SPRAGUE Owner Owner's Name information is required for CENTERVILLE MA , 02632 every page. City/I own State Zi Code 7/2/12 E. Report Completeness Checklist p Date of Inspection ® Inspection Summary: A, B, C, D, or E checked 11 lJF,JCI.UVI I JUIIIIIIGI y L/ koystei real lure Crit6rla Mf.JPlitaUIC to Alf JyJlCI11J).Go111pletteV 1 �1 ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 17 of 17 'Assessing As-Built Cards Pagel, t!`. ot't TOWN OF BARNSTABLELSCAMGN sEwALE A 777 V LLAGE t--.° [L,- - +T Y ESSOR'S MAP&LOT 224 INSTALLER'S NAME&PHONE NO. r7p t, j SEPTIC TANK CAPACITY t S-cr1? ��� f LEACHI ?t_:FACE..m: (type) f i nr (size) '_ NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE. /2— 3 COMPLIANCE DATE: Z--/S— 9 l� Separation Distance Between the. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet .-t 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 lemehifig faeiroy) Furnished by t i ;i'r BI - 2 ?' 13z i � .5 `ttp://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=248222&seq=1 7/2/2012 `4 r 2 TROY WILLIAMS P_ a SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE s OFFICIAL INSPE(:TION FORM — NOT FOR VOLUNTARY ASSE SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR PART A CERTIFICATION 2 Property Address: 61 Linda Lane Hyannis, MA O"ner's Name: Daniel&Cynthia Scioletti Owner's Addres.: 61 Linda Lane Hyannis,MA 02601 SEP 3 2002 Date of Inspection: August 26,2002 O TOWN OF BARNSTABLE Name of Inspector: Troy M. Williams HEALTH DEPT. Company Name:. Troy Williams Septic Inspections r5 Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (508)385-1300 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The svgtem Passes Conditionally [lasses Needs Further Evaluation by the Local Approving Authont) Fails Inspector's Signature: �� 2 � Date: 81. 4 16 Z The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. •""This report only describes conditions at the time of inspection and under the conditions of use at that time. I his inspection does not address how the system will perform in the future under the sante or different conditions of use. Title 5 Inspection Form 6/15/2000 Hare I Page 2 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 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 indicate at any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure trite a 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. Answer 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 with a complying septic tank as approved by the Board of I lealth. '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: At 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: iv 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 ..Sy,4.-- &o_,,{S ,.,s tt. 4. 1`?e ( p<<.) �.�t a�,;j„�.� �o� Wl,:i< l�o .<� yb.A,- 9Yopod- ��s ���a puss ; �y �aKa.�;��. -rb`• s �.4� �../y �.k:Nf a 6K�'{s wt QTh-r 1V plain: ,fl-.t 4l S y jt ,M ti w 71 �1 �+--_� ex 7lf� Tb r y ✓tl. L.•U u:-r�-'✓�Ck�a-c�.�.L. c..y..� �4v.�J✓y)✓w w'rA -TLo-%_s /tote to ew,n c- -F ��-..�3. 30 N. C.t.CA wui ►KSir✓e�4rl i7 PoSfiblt � lu,n,�✓q c.hd TC:t�I-» C-`6, L— pl ..+ b, .,4 iN4a j;hc 4, Yc r S�tfcq•r kKa cscSPoe, w,vv* �ti `�u,+tP�� �N� • Ilse !N 7WN�./ A1so G.jc�� {i.,f fa✓Stia� CA-.5�oS/wI vMvS�'<6c ►�L r,a✓o0� . /��� "s 4" 1 `_ y �,Iti,if f �.y�.. 0 �� c-.,� /�.,,b, �, s aq/JS l bt 7u`It�Jt /-0 OVsrYJ (t c .tiR:ai•�ul r-sy Op, co,»'p� a.-li rcr,4; rS• / 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION,(continued) Property Address: Owner: 61 Linda Lane Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti C. Further Evaluation Au equired 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. L System Hill pass unless Board of Health determines in accordance /marsh b)that the system is not functioning in a manner which will protect public heanment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetla 2. System will fail unless the Board of Health(and Public W er Supplier,if any determines that the System is functioning in a manner that protects the public alth,safety and environment: _ The system has a septic tank and soil absorptio system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wa supply. The system has a septic tank and SA and the SAS is within a"Lone 1 of a public water supply. The system has a septic tank a SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic nk 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 pas if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and vo tle organic compounds indicates that the well is free from pollution from that facility and the presenc ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure c 'eria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 61 Linda Lane Hyannis,MA Owner: Daniel&Cynthia Scioletti Date of Inspection: August 26,2002 D. System Failure Criteria applicable to all systems: t y , , You must indicate"yes"or"no to each of the following for all in ections: ASe.1_ 4 : hor.4- t p-,$ ) . 97 ftioKF 3y5fc», . �., Yes No i -3 -1cY -gc_c r- Sy y f�--- v&, 17 - Fvo,.j- s y s•r-ti _ ✓ Backup of sewage into facility or system component due to overloaded or clogL'ed SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day now _ . 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. Al Any portion of a cesspool or privy is within 50 feet of a private water supply well. &n Any portion of a cesspool or privy is less titan 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.IThis 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 ails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore thy 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 desig flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria ove) yes no — _ the system is within 400 feet of a surface drinking w er supply the system is within 200 feet of a tributary to urface drinking water supply the system is located in a nitrogen sen ' ve area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply w If you have gswered"yes"to any que ton in Section E the system is considered a significant threat,or answered "yes"in Sectipri D above the large stem has failed.The owner or operator of any large system considered a significant treat under Section or failed trader Section D shalt upgrade the system in accordance with 310 CMR 15.304.The system owner s uld contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 Check if the followine have.been done.You must indicate'yes"or"no"as to each of the followine: Yes No _ P::;:long information was provided by the owner.occupant,or Board of l iealth Were any of the system components pumped out in the previous two wceks 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? -Z _ 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: 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 unacceptable)(310 CMR 15.302(3)(b)) 5 Page 6 of I 1 OFFICIAL INSPECTION.FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 61 Linda Lane Owner: Hyannis,MA Date of inspection: Daniel&Cynthia Scioletti August 26,204LOW CONDITIONS RESIDENTIAL Number of bedrooms(design): `y Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): '/4/0 �,�� �, } Number of current residents: O + )- Does residence have a garbage grinder(yes or no):yc.5 Is laundrN on a separate sewage system (yes or no):W3[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):wo Water meter readings, if available(last 2 yearsltsage(gpd)): v t-6 2- /r/$ n o u/ram.,f ao- I ; Z,uU/ooa Sump pump(yes or no):L Last date of occupancy: ✓c., _F«t G., 2r12.2101 ,:.� Us.c C-, 4e.. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ,_gpd Basis of design flow(seats/persons/sgft,etc.): _ Grease trap present(yes or no): Industrial waste holding tank present(yes or no): _ Non-sanitary waste discharged to the Title 5 syste yes or no):_ Water meter readings, if available: _ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of informat ion: ,yn ,,, r<w, c st �"T-S;, , _tom' ��1 ;h `I Was system pumped as par(of t e inspection(ye or no): If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: _ TYPE OF SYSTEM vol Septic tank,distribution box,soil absorption system(Rt,., $y't"'' Single cesspool w*,4� y Gytl�s (�,0"4, >r�,� _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): QApproximate age of all components.date installed(if known)and source of information: /,car S`` ew, was h t /e.t/�d .. l� {G S p n� rye `i �< ) a t �� fZ�.. � i S Sri/y•�t4/ -�+ Were sewage odors detected when arriving at the site(yes or no): tvv 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 BUILDING SEWER(locate on site plan) Depth bolo" grade: /8"-- Materials of construction:—/cast iron ✓40 PVC___other(explain): Dkianct• front private water supply Hell or suction line: v/4 Comments(on condition of joints,venting, evidence of leakage,etc.): �1&4- W G- �A✓ u r i 1 S tl t c,.�o�. SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no)'_(attach a copy of certificate) Dimensions: �,�' x q, s- ', S—.o ' /Suo Sludge depth: I Distance from top of sludge to bottom of outlet tee or baffle: it " Scum thickness.- Distance from top of scum to top of outlet tee or baffle: _G Distance from bottom of scum to bottom of outlet tee or baffle: /r, llow were dimensions determined: pl-4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):P✓ �a —ware 1,'Ze,-', . ti A r CA ... a S -t. W G.-S �i✓L.4A -T�h h__ ,-j c—S $1,v GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_pol thylene_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 baffle: Date of last pumping: Comments(on pumping recommendations, inle d outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leaka ,etc.): 7 Page 8 of 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of pection)(locate on site plan) Depth below grade: Material of construction: concrete metal fibergla __polyethylene other(explain): Dimensions: -- Capacity: gallons Design floe: gallons/day Alarm present(yes or no): Alarm level: Alarm in working ord (yes or no): Date of last pumping: Comments (condition of alarm and flo switches etc. DISTRIBUTION BOX: (if present must be opened)(locate on site plan) ��w� Sy s+ 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.): 0-_3 J% s L✓5, A'da j, PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condi on of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why Type leaching pits. number:_ leaching chambers,number: $_ I F:�t, c,04 4. 7 ;ti '�f� y� w K y,51-&, 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.): /� I 4-,..- �.�-�/.,..( l✓u �"b./'.'..d// /o ig.__�tu�. .-,s vi't /C' .h t!1-r.�- j p<<�;�ti. CESSPOOLS: (cesspool must be puZ locate on site plan) Number and configuration: Depth—top.of liquid to inlet invert: Depth of solids layer: Depth of scum la%er: , _ Dimensions ofcesspool: Materials of construction: Indication of groundwater inflow(yes or o): Comments(note condition of soil,si 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 ure, level of ponding,condition of vegetation,etc.): 9 Page 9 of I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 SOIL ABSORPTION SYSTEM(SAS):,�(locate on site plan,excavation not required) If SAS nut located explain why., Type leaching pits. number:_ leaching chambers,number: leaching galleries,number: 4/ 6_rtc7, z S leaching trenches,number, length: _ _leaching fields,number,dimensions: overflow cesspool,number: T innovative/alternative system Type/name of teclurology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, dam etc.): p soil,condition of vegetation, CESSPOOLS: v1 (cesspool must be pumped as pan of inspection)(locate on site plan) Number and eonf iguration: h�i G . r, c 2�Sr. b t - Depth-top of liquid to inlet invert: Depth of solids layer: Y Depth of scum lay er: Dimensions of cesspool:_L_�X Materials of construction: �.� -�, to c%_ ..__ Indication of groundwater inflow(yes or no): lya Comments(note condition of soil,signs of hydraulic failure, level of poJnding,condition of vegetation,etc.): _ / L.fi1—�.Lt� > wu 1 1 ..— CtS„ST�s d r H S C_� S �_Qa r-tr ti a C.u . PRIVY: (locate on site plan) Materials of construction: Dimensions: --_ - -- Depth of solids: Comments(note condition of soil,signs of hydraulic ure, level of ponding,condition of vegetation,etc.): 9 " Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Hyannis,MA Owner: Daniel&Cynthia Scioletti Date of Inspection: August 26,2002 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. �—r--- 1:„. y K:a C t' . .t L..�.,i-d-✓ Cyr S`000 1 qc; k.k��,�� ,V y �,wu<ti -&T O O O1 1 � I 1 ` 1 1 10 Page l l of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 SITE EXAM Slope Surface water Check cellar ✓ Shallow wells Estimated depth to ground water YJ.V feet Adjusted high ground water elevation.?? y 'feet Please indicate(check)all methods used to determine the high ground %%ater elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ,a. « Checked with local excavators, installers-(attdch documentation) --V_Accessed USGS database-explain: /1,4: You must describe how you established the high ground water elevation: / US (. S G' ...,.A_�,�.o f �•. s �"—d?.-..,. s--�L).— 111. t ✓7 �. 4-�� / TI_J�.. .�b 3 G�.,dl J( w u`+--✓ --4-_ t./--o-4,- —' �� Ll IAA- f 6;u' 3� Y, y3y Bpi'-�' yd� -' '•1�5(� �,,,,.-.,1 V,,�...i (;any-(,- • 6a error..v y G�-w.� w�1•..✓ ,e.(.s,.�e.�b ti II No. 1 ' Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Y11"../ 01pprication for Mopooar bpztem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) )2TComplete System O Individual Components Location Address or Lot No. t ukw* Owner's Name,Address and Tel.No. 1 `� �. Assessor's Map/Parcel , y�.vM �, SG o' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �D `��AtE-'CG✓ 1� g,�-e 6t 441vt�t> Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank D Type of S.A.S. ° Pc?T o�t�c r rc Description of Soil 5 Nature of Repairs r Alterations(Answer when applicable) C4,0L t c.Tc tom-- Sru�.a rQ �4 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 a the system in operation until a Certifi- cate of Compliance has u y this Bo h. 1 Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. '1_ Date Issued 61 �r 0 A�' A2 -` 6z -' . TROY WILLIAMS SEPTIC INSPECTIONS TO Certified by MA Department of Environmental Protection .(508) 385-1300 19 Hummel Drive South Dennis,MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ProperIN Address: 61 Linda Lane Hyannis, MA Owner's Nnmc: Daniel&Cynthia Scioletti Owner's Addres.. 61 Linda Lane Hyannis, MA 02601 Date of Inspectiort: August 26,2002 Name of Inspector: Troy M.Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis; MA 02660 . Telephone Number: (508)385-1300 -CERTIFICATION STATEMENT I certify that.l 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. 1 am a DEP approved system inspector pursuant to Sectinn 15.340 of Title 5(310 CMR 15.000). The syttcm• Passes Conditionally ('asses Needs Further Evaluation by the Local Approving Authom) Fails Inspector's Signature: 7.J� �. Dater 16 2 The system inspector shall submit a copy of this inspection report to the Approving Authority(Hoard of lealth or DEP)within 30 days of completing this inspection. If the system.is a shared system or has a design flow of 10,0o0 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection;certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""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. I Title`S lntnerlinn Pnr fit tnnnn =To Reorder:1-600-225-6380 or www.iiebs.com I - — yr zsu RTOLOTTI CON � - -- -Bc)- OD0DTf t. CTION, I C. 0OR HOEn P.O. 8oz�, 0� ' ' ; MARSTONS MILLS` MA 02648 (.! . 508 0943 j � ) 771-9399 508 428- OAT ORDER� ) 8926 � . AER'S ORDER NO. PHONE ` ` MECHANIC H _ _ ELIo ER STAR G DATE ORUF_R TAI :N Y�j�1 �G } a� �� /// /� ��L'1: � ❑ DAY WORK `—-CONTRACT � lf�� �-�L.�/ v! (�V<�.� ❑ EXTRA .. urn PI IONS—� TOTAL MATERIALS 1 TOTAL LABOR II TAX iPLETEDWORK ORDERED DY TOTAL AMOUNT S r ; n No n—hn— n Tm.1�mnr Inc r Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION (continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel 2 Cynthia Scioletti f August 6,2002 (� Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicate at any of the failure criteria described in 310 C►�4R 15.303 or to 3 10 CMR 15.304 exist. Any failure crite a 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. Ans�vcr yes, no or not determined(Y,N,ND) in the fqr the following statements. If"not determined" please explain. ,Q 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 liealth. '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: Al 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): ��u �•.v ,Q/)�N /},(� Tyr' broken pipes)are replaced obstruction is removed N'f� `r '��'` distribution box is leveled or replaced /�L:wli/L 1A ND explain: N 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 Sys+•.— fq s ( ) w �f�/J `►od. vim, �b....a ;.� pu.-S 3L; „7 co`..�1 /i o .. -r4'. S ��.� o•.ly ) bw s o"rk AND explain: fl,.ti, 4l �r. Sl.3�c M� h 1�T j b.� ✓t� 2Lll w-� ✓�&.4--1,-- C. -t /�'y' ,.1 " " Y'. l.W- , �s n.k-e W i 1'1. ��•ti<.s /tit C. K crt.. G. + lJ(.. 1. 9 0.". L1 L.CA %.a S I h s i lo Ss ! l.tt.ih r7 c.h {G. (,... Gn., b p I..,..b a( 4 O f t 1/^1� rt ..L/� � •. !N-�"L ��1.c '-�br .Y<.�•.✓ s'f S f'�-�+1 4 h Jl G c�SI Poo t rhv yr q.t� -!•�u...� O�-u� (rN ut ?"� l t�t.� !M 7YOnYt�-. A�3a Grti.a...Q:�i•d..c c.l ►+cSsaS �.— „ia.�fs ?Yuw, 7� -A / �e.S ^,,v4. . `q►1 7 � 014 0.4 f�,%6,h ft"s4- a—$ ,, opot, G JfrcNars• P ��4L SC f�f.J�IMf-uo S O�'V Gbr rJt� / � -- Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 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 indicate at any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure crite 'a 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. Answer yes, no or not determined(Y,N,ND) in the fRr 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 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: At 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: Al 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 Syj�.... ,., bw�k '•^s�tt�� . ., 1Yye ( p<<.) ���ca<>;f.,�.� �,. W�,1:r<. l,e,.,<� yN�.�.... �rYV G V4S ✓«� N �(l+ZiSsl bl��1 Cs K.11.•�fN. TN• s l✓4S 01 ry R.y�s a 6g7� S Gi� pt k='•_,MeX lain: �1 �JI'j�+ Sy 7,> fi Tb•- �f ✓tY �Uu.l'✓✓�Ck� I-�(�oa, c..�� t4vHrlr./)�'w� {ti✓•n•� � .n I.+r�. �s�^kP wi'� �uw,oi A,%c tC GwH C-+ 61--3. 3044. C-A motif II.1.3-1'✓✓e��.dt'7`j4T� (�uSsl614 �ct�ti.iry c.�d/1{G:L.I.. c•►►, b�- PI-.,.•b+d( �r rt•.r S�sf«+ti yKA ult pool =v1 v yfi �Ss. -Y✓`h pt'� G-N�l •tl /( f� N h�. 117/t$ O L>L i 1 47'h 4 4 G.r-4 44.E cA- S �7 o S/-fL I Kr v S}" •L . r—dr CP�/od/. /��r/ Mrs s4 1 a�-� �..ii..is 1., fJ o 14 G�;+.`Jt:ai•«ci 1 P K S g VP o i, C a,^!o I �-�i o r o /^cr a;r i• / --- -- 2 r Page-3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 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 15.30 1)(b) that the system is not functioning in a manner which will protect public health,safetXmarsh 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 s 2. System will fail unless the Board of Health (and Public W er Supplier, if any determines that the system is functioning in a manner that protects the public alth,safety and environment: _ The system has a septic tank and soil absorptio system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wa 4upply. _ The system has a septic tank and SA and the SAS is within a "Lone I of a public water supply. _ The system has a septic tank a SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic nk 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 pas if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and vo tle organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure c ' eria are triggered.A copy of the analysis must be attached to this form. 3. Other: :_.`__ 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 61 Linda Lane Hyannis,MA Owner: Daniel&Cynthia Scioletti Date of Inspection: August 26,2002 D. System Failure Criteria applicable to'all systems: �"� S y s �••, aN t y ,.� You must indicate"yes"or"no"to each of the following for all in,5pections �r sit� .c : fi by r p�S i . ->� a- 3ysf<<.. . TC,s Yes No i 5 ON 1y . F,-L>..F $y1t wc.s :l i✓t _ ✓ 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 ''/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 well. - ivt.9 Any portion of a cesspool or privy is within 50 feet of a private water supply well. &n 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 forma Nv (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. I� S y, t- 6" 17 E. Large Systems: To be considered a large system the system must serve a facility with a desig ow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria ve) yes no _ the system is within 400 feet of a surface drinking w er supply the system is within 200 feet of a tributary to urface drinking water supply the system is located in a nitrogen sen ' ve area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public water supply w If you have answered"yes"to any que ton in Section E the system is considered a significant threat,or answered "yes"in Section D above the large stem has failed.The owner or operator of any large system considered a significant threat under Section or failed corder Section D shall,upgrade the system in accordance with 310 CMR 15.304.The system owner s uld contact the appropriate regional office of the Department. _ _ 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 Check if the following have been done. You must indicate'yes"or"no"as to each of the following: Yes No _ f ;:;ping information was provided by the owner. occupant, or Bu�Ir,i of I Icald, Were any of the system components pumped out in the previous two weeks j/ Has the system received normal flows in the previous two week period '? _ .1/—/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) ,L _ 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: 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 unacceptable)(310CMR 15.302(3)(b)] ' I 5 Page 6 of I I OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 61 Linda Lane .Owner: Hyannis,MA Date of inspection: Daniel&Cynthia Scioletti August 26,2009LOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 4/ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 41Yo Number of current residents: O 4- Does residence have a garbage grinder(yes or no): PCs Is laundn on a separate sewage system (yes or no): YYf3 f yes separate inspection required) Laundry system inspected(yes or no): Seasonal use: (yes or no): va Water meter readings, if available(last 2 yearsLsage(bpd)): 0 t-v 2: /y� o u 1,,,,, ov t : 2-00�000 Sump pump(yes or no):A Last date of occupancy: ✓c COMM ERCIAL/INDUSTRIA L Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): _ Non-sanitar % e discharged to the Title 5 syste yes o�no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: NU Was system pumped as par(of the inspection(yes or no): ,yo If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe):. Approximate age of all components. date installed(if known)and source of information: L l`�r SY��t-w. Wt�S .h� fc..l�c.! . V SQ �n� 1 �-�C..0 � �a � i ♦ TW.a � I / �Yty•LI�.IT �..»a c, �,,..�r G h.lr�y s r+*.r< c�•Q-�.s..t o 4 7/z 3/�� !��-w- 4 s-b..�t fi. Were sewage odors detected when arriving at the site(yes or no): LL) 6 Page.7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 BUILDING SEWER(locate on site plan) Depth belwk grade: /8"4- Materials of construction: //cast iron _✓40 PVC_other(explain): Dittanc:• From pri\ate water supply well or suction line: "V14 Comments(on condition of joints,'venting, evidence o1 leakage, etc.): SEPTIC TANK: (locate on site plan) ( (Lw. SyS4- Depth below grade: I Material of construction:_concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no):'_(attach a copy of certificate) Dimensions: _ $�,S x 9.s' 'x s. I so u j 0. ,�o Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or bafllc: G '' Distance from bottom of scum to bottom of outlet tee or baffle: /r, I low were dimensions determined: jam.,.L Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.j: P✓ L T t; w �a'..,J. ; w u �.:...�9 .a v R �✓v_c -� 4 _s� c:l�s-y-c A r rt c .c. - W 4-S ✓c. Tc.., k .J�-S /�o �- ti n c �C J �' � GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_pol thylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom/etc.): baffle: Date of last pumping: Comments(on pumping recommendationet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of lea _. 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of' pection)(locate on site.plan) Depth below grade: Material of construction: concrete metal fibergl _polyethylene other(explain): Dimensions: Capacity: gallons Design Flo%%. gallons/day Alarm present(yes or no): Alarm level: Alarm in working ord (yes or no): Date of last pumping: Comments(condition of alarm and flo switches, etc.):_ DISTRIBUTION BOX: (if present must be opened)(locate on site plan) �;.� Sy S+�,• Depth of liquid level above outlet invert: 160c,l. x. Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover. any evidence of leakage into or out of bo/xJ etc.): 0 (77 <J-tom G� .� .�✓ b PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,cZonofs and appurtenances, etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) Fol If SAS not located explain why: 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.): '�•J y 1-,�- l,w.__ t w s.�F �e..,,,.d/f�,h—.(.c a�.L. -�.., ...+ 6.,a CESSPOOLS: (cesspool must be pumped as part oZinspecti, locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum la*er. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow ysiofohydraulic Comments(note condition of soil 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 rue, level of ponding, condition of vegetation,etc.): 9 r - - Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Owner: Hyannis, MA Date of Inspection: Daniel&Cynthia Scioletti August 26,2002 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 7`b r if SAS not locate explain why.. Type leaching pits. number:_ leaching chambers, number: leaching galleries,number: _Y G-i(,,7, ji� 2 `S f-r,•,t• 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.): r�—•- ��_i�c�� l. � fz. (..� c.�.� �� �i�-�t ��ram' CESSPOOLS: -3,—/ (cesspool must be pumped as part of inspect ion)(locatc on site plan) Number and configuration: k" Depth-top of liquid to inlet invert: Depth of solids layer: 3 Depth of scum Iat er: NOi>F Dimensions of cesspuol: Materials of construction: Indication of groundwater inflow(yes or no): ,yo Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): �fa W r .c ✓ .. / h a _Nc.... c c. t.c �r l d PRIVY: (locate on site plan) Materials of construction: _ Dimensions: Depth of solids: Comments(Rote condition of soil,signs of hydraulic ure, level of ponding,condition of vegetation, etc.): -_ '»: 9 Page 10 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 Linda Lane Hyannis,MA Owner: Daniel&Cynthia Scioletti Date of Inspection: August 26,2002 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. J, j<C 4�L, .� C-r S�Qov I 3z , 3 � ZU a &ro 0 0 G• z11 t 0 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Linda Lane Owner: Hyannis,MA Date of lnspei tion: Daniel&Cynthia Scioletti August 26,2002 SITE EXAM Slope ✓ Surface water Check cellar ✓ Shallow wells Estimated depth to ground water Y,3.V_ feet Adjustcd high ground watcr cicvation3? y "feet Please indicate(check)all methods used to determine the high ground %%ater elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within I50 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attdch documentation) Accessed USES database-explain: it,4: t q 2 ash / S• J o ✓- You must describe how you established the high ground water elevation: USG OC U 712 ..J cam_ U ..U_n e.(_ ,w-"S —�'•��1 o- "" aS�- �o e,e.. e e f I _ _ 3- Y� L � r 11 l No. a 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. - Yes • PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplitation for Mi5po5aY �pStem CZons1ruttion i3ermit N Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) )?rComplete System ❑Individual Components Location Add=or Lot No.Ox` E—wo E- (.6t_2_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel \ �y�•vi(r 6 Sc O 1 r__TA_T Installer's Name,Address,and Tel.No. d' Designer's Name,Address and Tel.No. Type of Building: '1{/ Dwelling No. of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building TT� No. of Persons Showers ( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow "1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank PO Type of S.A.S. _ • v Description.,of Soil S Nature of Repairs or Alterations(Answer when applicable) STI� ( d �Q C-1 'iL iE 5 t 0,y Srv--�e_o_ x 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 n1ace the system in operation until a Certifi- cate of Compliance has ue y this Boar th. \ Signed Date ��� Application Approved by Date Application Disapproved for the following reasons Permit No. n Date Issued T � �, •o lil. lei.: �.v��"r'�i� i tt � s Ci F1ME Tow Town of Barnstable Regulatory Services snxxsrnat.e. 9 MASS. g Thomas F. Geiler,Director �p 1639. �0 ° Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 19, 2002 To Whom It May Concern: This letter is to confirm that as of September 18, 2002 the septic system located at 61 Linda Lane, Hyannis, Massachusetts, is no longer in a conditional pass status. It passes per the Town of Barnstable Health Department due to the fact that the single cesspool was pumped and properly abandoned by filling it in with sand. All the plumbing in the house now enters the Title V septic system on site. Sincerely yours, C 1 IZ9,1 Donna Z. Miorandi, RS Health Inspector Enclosure: copy of plumbing inspector's approval copy of abandonment work 4 h TOWN OF BARNSTABLE , N IA— SEWAGE # gF--7 7 Z .41 LAGE �E k&SSOR'S MAP & LOT Z q tt a?Z INSTALLER'S NAME&PHONE NO. —GAS b SEPTIC TANK CAPACITY LEACHING FACIL=: (type) 3��1 C'/` t v (size)L—T✓`'��i NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: /2 3 a COMPLIANCE DATE: Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 A s No. / Gj Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC-HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Digpogaf *pttem Con.5truction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) )h'omplete System ❑Individual Components Location Address or Lot No. ` LA yv14- UV-,P-- Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 C.\ ys ///{C ��-0'CAT Installer's Name,Address,and Tel.No. ci Designer's Name,Address and Tel.No. —7--A-0 �jiv t4 writ 4t> Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures r c Design Flow gallons per day. Calculated daily flow "1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank O Type of S.A.S. a s5 Description of Soil s Nature of Repairs or Alterations(Answer when applicable) Sr�C IJ d —G ` c>c cZTrrc.Tc t� t.�-- QW S V"-e,ai66 2 4q 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 a the system in operation until a Certifi- cate of Compliance has sue by this Boar th. 1 Signed Date O�� Application Approved by Date ✓`Z"07-- Application Disapproved for the following reasons Permit No. n —7-7 Date Issued � "� No. .�J ~`/ /G� Fee It m THE COMMONWEALTH OF MASSACHUSETTS Entered in couteri.-`p/ 'fes PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ,': A 01ppYtcatton for ]0t9;po2;a1 *pgtem Congtructton Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon,,( ) :Momplete System ❑Individual Components Location Address or Lot No.�, (-k V_10 - 1 Owner's Name,Address and Tel.No. 'Assessor's Map/Parcel /7.V,4A- /L,4 Installer's,Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures tt C, Design Flow '"t U gallons per day. Calculated daily flow y� 1 gallons. Plan Date Number of sheets Revision Date Title `�i Size of Septic Tank I S O �V\t;. Type of S.A.S."" ` ���'�r t �T$D`�� �41a�� CT Description of Soil V`ry eL— S Nature of Repairs or Alterations(Answer when applicable) 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 a the-system in operation until a Certifi- cate of Compliance has ssue• by this Boar th. Signed ► Date Application Approved by �' Date Application Disapproved for the following reasons r Permit No. -T All Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certtftcate of CompItance r :a THIS IS TO CERTIFY, that the On-site'Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by •t --c- -e . ti at (at `c u. 4 ci. ��Z 7,Ut has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. V X" 72-,aated Installer Designer The issuance of this permit shall of be construed as a guarantee that the syste ��w�i function asAogned. Date -Z Inspector No.. � '� G^ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS V 1tgpoga1 *pgtem Congtructton Vermtt Permission is hereby granted to Construct( ) epair( )Upgrade( Abandon( ) System located at C k��- L v�i—v c,t and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thi t. Date: �" Approved r 1019l97 NOITICE: This Form Is To Be Used For the Repair Of Failed F ' -Septic_Systems Only:, 9 'CERTIFICATION OF SKETCH AND APPLICATION FOR A a DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) pcQ � �� , hereby certify that the application for disposal works construction permit signed by me dated concerning the ,�„� T,e,,, meets all of the property located at 62 f w��' �-- � ' following criteria: , I • There are no wetlands located within 100 feet of the proposed leaching facility , • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed ere are no variances requested or needed. _ o If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will I14.t be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please'complete the following: A)Top of Ground Elevation (according to the Engineering Division G.I.S. map) ��,f� B)Observed Groundwater Table Elevation(according to Health Division well map) ci7 � �dlT� t SIGNED DATE: LICENSED SE rICSYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i i q:health folds:oat I , Y 1 �� l c o � � t �� � F- .:. � y e �' � _.. e. � ^- "^..."w� I o 1 - TOWN OF BARNSTABLE L TION �—i N o A- 9�7 7 SEWAGE # Z �p VILLAGE C 7V=44-( 21-A ASSESSOR'S MAP& LOT 2��- 22Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY t 6?2 LEACHING FACILITY: (type) - 3� (size) ���-1✓�Tll�� NO.OF BEDROOMS J BUILDER OR OWNER PERMITDATE: 12' 3 g COMPLIANCE DATE: /Z—/ 9r I 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 r fir L LW TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE °rn�' � y� - ASSESSORS MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) `�,-(, VQ'1 S (size) o1 4$ NO. OF BEDROOMS PRIVATE WELL OR yUB IC WAT OR OWNER 4�f\ y�-f7 I�� I, DATE PERMIT.ISSUED: DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No � R o - TOWN OF BARNSTABLE .00ATION Ca S\( �7Y_V SEWAGE # `JILLAGE 44��t o, ytv- yASSESSOR'S MAP & LOT T1� INSTALLER'S NAME & PHONE NO. 1<<,�X �v I��✓�� SEPTIC TANK CAPACITY C 5-6 S P,:o) 600 n tta w LEACHING FACILITY:(type) (size)-4- l aX g- NO. OF BEDROOMS PRIVATE WELL PUBLIC WAT BUILDER OR OWNERS DATE PERMIT ISSUED: Q DATE .+COMPLIANCE ISSUED: f VARIANCE GRANTED: Yes No r f n _ - f51 g 6 2 v a o � F �l - No... / d - Ficis THE COMMONWEALTH OF MASSACHUSETTS ^I BOARD OF HEALTH fL P/ ... r . .w ......---�------------------------ Appliration for Disposal Works Tonstrur#iun Frruti# Application is hereby made for a Permit to Construct ( ) or Repair ( n Individual Sewage Disposal System at . Location-Address - or Lob No. .�............ .c�� . ................ ................... ------------------------ wner , ` ................... O adress Installer Address Type of Building ____Z Size Lot............................Sq. feet a Dwelling—No. of Bedrooms............ ............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.--......................... Showers ( ) — Cafeteria ( ) dOther fixtures -----------------•-----------•- ------------------------------------------ --.--------------_.. ------------ W Design Flow...........:S. -................gallons per person per day. Total daily flow.......�..�...0.............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width.......------... Diameter.------......... Depth................ x Disposal Trench—No. .....I............. Width....2........... Total Length...... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.........--......... Depth below inlet........--.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank (. ) 0.4 Percolation Test Results . Performed by.......................................................................... Date......................................... 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit....--.............. Depth to ground water.....................--. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .-------•--------------------------•-----•------...--------•-------•------.....................•--•-•......................................................... 0 Description of Soil............................. U .....--•..........................•---.....................--------.....-------•-••----•-•-•-----------...-----...------.........--------------.....---------••----------•----•••-•-•----•••-•---•--•---- W ---•-------------------------------------•-•------------------------------------------------------•-----------------------------...---------------------------------------------•--....-------------.-- V Nature of Repairs or Alterations—Answer when applicable.......... Y ............!;;).-.---.-- Agreement: -✓ The undersigned agrees, to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'LIT LIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the boa d of h t 1 ..� �q ` --- ----•. ---- -- .... Application Approved B Pp PP y •----•----•--••••••.......................•..... .-•-•• d. .. / Date Application Disapproved for the'f ollowing reasons:-----•--------------•-••---............................................ ....................................... ....................•-•.....••••-------•....-•-----•-----•--••-•---•-••••----•--•--•-•-•--•-•-•--••---•-.............-----•-----•-•--------••----••-•-------=•--•--•------•-----•----...----............. ` Date PermitNo......................................................... Issued_....................................................... Date No:!E2 2_P.5& Fxic .. ..........- THE COMMONWEALTH OF MASSACHU,SETTS BOARD-OF HEALTH tPlf- OF.......... .. --e /C-P Z_ Appliration for Disposal Works Tonstrurtiou 11trutit Application is hereby made for a Permit to Construct or Repair L),an"'I'ndividual Sewage Disposal System at: .......... rue ............................. .... ......................... ­- --------*-----­-­---------- Location-Address or Lot No. ....... -------------- ....................... ----------------------*---------*---------------­' Address ............... ............. .A:A --- ------------------------------------------------ Installer Address Type of Building U Size Lot...........................Sq. feet Dwelling—No. ...........7>............................Expansion Attic Gara 9 e Grinder N�1 of Bedroomsb.Other—Type of Building ............................ No. of persons.......__..........__._.._.. Showers Cafeteria <04 Other fixtures ........................................................................ . ...............­........................................................... W Design Flow.......... .................gallons per person per day. Total daily flow........... .............gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width......_.._...__. Diameter----_---------- Depth.....__......... W Disposal Trench—No. .._...(............. Width_.....__.__.....2.1........ Total Length...... a... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.............._..... Depth below inlet........._......_._. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( - ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water:......._......._....._. 44 Test Pit. No. 2................minutes per inch Depth of Test Pit........_.......___. Depth to ground water....._......_........... 0 9 *......*"---------------------------*............*----------*..........*­-------*......*-------­------------*-------------I-------------*...."-----------­ Description of Soil.................................................................................................................. ..................................................... ------------------**-----------------------------------­*---------------------------------------------------------------------------------------------­*------------------------*------- ...................................................................................................................................................................... ..........................6...... ..,-A114, U Nature of Repairs or Alterations—Answer when applicable._------.- _V7\0-------------D--------- ...... ....................... ...... ........yqy ------7::X2... . ....... .... 15?�o ................................ Agreement: _XA The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ;;—--------- Application-Approved By................... 4. /lZa ........................................... ................................... ........ ................. Date Application Disapproved for the following reasons:............................................................................................................. ....................................................................................................................................................................................................... Date PermitNo.......................................................... Issued...................................................... Date -—————————— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 F. ............................. Tntifiratp of Tampliana THIS IS TO R_TIFY, Tha the Individual Sewage Disposal System constructed or Repaired by.............. .......... _.c............................................................................................................................... Installer I............ .......... .......... -.I2........ . ............. ....................................... at.......... ..... r4 has been installed in accordance with the provisions of T ITLE, 5 of The State Sanitary Code as•described in the application for Disposal Works Construction Permit 1�'o ------ d-at.................X� 1 .................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. .....2.... ........................... Inspector— .................................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -kA_1...fi..—.,6 F', v ,_s-�c_L ............................ ............................. NFEE........................ Disposa Ararks,19-onstrWim Vamit Permission is hereby granted______________ --- ---- --- ..I............ s�.......................................................................... to Construct or Repair ( `)_an_Individual Sewage Disposal System atNo.. I ----------('_W... -----------_---------- Street as shown on the application for Disposal Works Construction Permit (Dated.)---------------i..............W....... .......................... .................................... DATE_._........ / E;& Boiird of IfCAth ................................................ ELLIS 6? THULIN, INC. LAND SURVEYORS CIVIL ENGINEERS 478 ROUTE 6A-PO. BOX 159 DAVID C.THULIN, PE EAST SANDWICH, MASS. 02537 JOHN R.ELLIS, RLS TELEPHONE (617) 888-2345 JUL..Y 20 , 198 367 i•'ii'`iIN ST1iEE* HYANN:IS, MAS :ACF•It. SETTS, O d 60:1. RE: AS—BUILT , LOT 78, LAKE SHORE: DRIVE, "L.(aNG POND FARMS, " MILLS , MASSACHUSETTS REF! E:ARN :iTi°•tBL.E: SEWAGE PERMIT NO U6....:1.077 (DATED l"lt::Tt:1BE:R III . 1986) -- BARNSTABI...E: CONSERVATION COMMISSION DE:UE FILE NO ., SE 3-1503 (ORDER DATED D OCTOBE:R 21 , :I.9S6 DEAR SIR THE. SEPTIC SYSTEM M ON THE:. ABOVE—REFERENCED LOT APPE::iiiF~i: TO Ht:F741'E BEEN INSTALLED :IN SUBSTANTIAL COMPLIANCE WITH THE F'RO O :iED PLOT PLAN DATED 9....17 -86 (REVISED D 9...30••-k: 6 & :1.0 --0:L••"86) v THE ENCLOSED UPDATED CERTIFIED PLOT PLAN DEFINES THE PROPOSED/EXISTING LOCATION OF 'T'I••11E SEPTIC SYST'E::M., l ELLIS t; T HUL...IN, INC. 1 I I mk1 PROOUCf 95-2 Inc.,GrtRan,Maa 01450.To We PHONE TOLL FREE 1+80011SR3R0(Man resident 1+801F252.9226) A O O O p b 7'V DATE O :3 V 'j AYOTTE CONSTRUCTION INC. 25 Shaker House Rd. P.O. Box 1052 SANDWICH, MASSACHUSETTS 02563 NUMBER '� 888-3176 888-6691 v o a. 2 c e... Lna to :� m U r" o ~ 0 Q M 3 O ��{{w//nll• + 0 ; C TERMS: ey-r f D W! v D PLEASE DETACH AND RETURN WITH YOUR REMITTANCE • • O T A i�' 7, AR0.ES yAND�CR a gp d �. BALANCE FORWARD q', > N J U) 0 .► 1) c td '? . � f i , o 3 r ; : v `l 3 tg nz0 i O > r ,. ILI- D Z . C) � rnm1 m < ' 1 Z � c. U, , i _ . :E) � _. � z PAY AMOUNT AYOTTE CONSTRUCTION INC. 1 i'U/A�.I�nL[R�J• p�,� 1N THIS IS COLUMN -F3/D+� 103-41 00 ✓y`✓ �C r m N a 0 Lo a Qom, � \0. r*i 47) A Ioo 1 o bhL. \ QO v 7is,�rxmoN �� D 'C) UA ��>�PfZcr poi D tJ -� • ��v 6. �.P �� 2'---Tcm"E 00 A� C3u�crr .• . 160.0().t S0546,00-W_ 4 N 000 Q Ul -0 �: DEQG FILE ' No. SE 3•1503 { vlG '. 07- 20- 5-�. CE�TII>=b P.LrT. . ALAS! LOT 78 LAKE S.FIpRE- URIvE LONG POND .FARMS PE--�i T Ha3�- t o� DA i D 10 4.e Co M A R STOtA N I L L S M � Sr�4 L 2=: I = 40 pl�i 2 24•� ct.IFJ-tT: RI LCY = NEQ g-r C�ILTtF�( -rz_IA-r 7t4C- ALL 1: 8=,•T74ULIQ I C- .�c;g,ts 6- 1.15 476 i= Gq Lc=�rr 15 L=cA•TED I!-.i P LP�to►_! Ta DR gY: FsT 1r4E �clsnub,&.OLY JMEFwrs =5tb ,J EFAST 'SA JJ D Q►G-{ M A • 02537 c,-I• eel: •SHE�7 I of I