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HomeMy WebLinkAbout0071 CAP'N CARLETON'S RD - Health 71 CAP CARLTON AM6 COT'UIT A = 038 058 T r t f _ W., -: TOWN OF BARNSTABLE LOCIJION 7/ Goo 6?Y,,1 ,&PW /V SEWAGE # 24V®✓375,( VILLAG Aal2r ASSESSOR'S MAP & LOTAM—O r INSTALLER'S NAME&PHONE NO. . �d�Y�� l C©�57: 77/-gy SEPTIC TANK CAPACITY chc� GA LEACHING FACILITY: (type) PO eiA ltw.-f NO.OF BEDROOMS 3 BUIl DER O OWNER PERMTTDATE: Z � COMPLIANCE DATE: . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sfi Feet , Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) °, ` R/& Feet Edge of Wetland and Leaching Facility(1f any wetlands exist ,t within 300 feet of leaching facility) /V Feet Furnished by bCy d Y 2 � �i v �� `t` \ �'` ` i No. fie.�M � s✓ Fee`' a` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplitation for Migpooal *pgtem Construction i3erm it Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System L�Individual Components Location Address or Lot No. Owner' Name-Addres5 and Tel.No. Assessor's Map/Parcel Go, ,Lv 9 Installer's Name,Address,and Tel.No. / / Designer's Name,Address and Tel.No. CDI151217 77i-9 9 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(✓00 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /A�) gallons per day. Calculated daily flow j J D gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank DGb Type of S.A.S. G W Description of Soil 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 place the system in operation until a Certifi- cate of Compliance has been issued b this Bo of ealth. Signed Date Application Approved by _ r Date Application Disapproved for the following reasons 1000 Permit No. �' Date Issued "' d �Ja ,,11�� J� .. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for �Digpogar *pgtem Congtructton Permit Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) El Complete System �idividual Components Location Address or Lot No. /" Owner's Name,Address and Tel.No. ''7 Assessor'sMap/Parcel ( / `��� r�af/ro� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 64P� Type of Building: Dwelling No.of Bedrooms : Lot Size sq.ft. Garbage Grinder Other Type of Building 42 No. of Persons Showers( ) Cafeteria( ) Other Fixtures c Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Pate Title Size of Septic Tank Type of S.A.S. Z / Description of Soil 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 do-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date a Application Disapproved aft o o n ens Permit No. . Date Issued •-.� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ,)Xpgraded( ) Abandoned( )by at has been constructed in accordance with the p ovisions o Itle 5 and the for i posal Sys em onstruction Pe'rmt 2�0dated _ Installer Designer. Pr V The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date r-- � Inspector_ � ,i ' --------------------------------------- No. � ..���� �✓ U Feed THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwfgpogar &pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( Xpgrade( )Abandon( ) System located at 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 this pepriit. Date: Approved by l NOTICE:This Form Is To BeVsed For the Repair Of Failed Septic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) L Whiel' - X hereby certify that the application for disposal works construction permit signed by me dated 1®e concerning the property located at 7 Orl meets all of the following criteria: V/ The failed system is connected to a residential dwelling oniv. There are no commercal or business uses associated with the dwelling. The soil is classified as CLASS I and the oe.=iation rate is less than or equal :o'f minutes per in V11'Fhere are no we•.lands within 100 feet of he rrocosed septic system Y ?"here are no private wells within 1:0 fee:of the proposed septic system P . .6/ There is no increase in flow and/or change in use proposed The:a are no variances requested or needed t/ The bottom of the proposed leaching facility will not be located less than five feet above the ma..,dmum adjusted groundwater table elevation.(Adjust the groundwater table using the Frimptor method when applicable] V✓/If the S.A.S. will be located with 250 feet of any vegetated wetlands. the bottom of the g PropoSed leaching facility will not be located less than fourteen(14)feet above the ma:dmum adjusted groundwater table elevation, Please complete the following: . A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation e +the MAX High G.W.Adjustment. Z C • 3 DIFFERENCE BETWEEN A and B Z " SIGNED : DATE: 6�Z!®lam (Sketch proposed plan of System on bwk). �haft hk1w an ��0 9 o a Palo j JI J Z �pd y,4/l�� 0 z r�o�6�'r5 G ---------- TOWN OF BARNSTABLE LOLOCATION '71 7" 45:;Me IMe AV SEWAGE # 24!�'0-7?7� I VILLAGE 692"I'al 2` ASSESSOR'S MAP & LOT-Or i INSTALLER'S NAME&PHONE NO. 7�71-ey SEPTIC TANK CAPACITY jove LEACHING FACILITY:Jtype) RIO eOl la'if C4dwJ, (size. ) 12,-f NO.OF BEDROOMS-3 1 BUILDER 01�SY7;NER pare*/ PERMrFDA COMPLIANCE DATE:. Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility). Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by es Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: CS +4 BUSINESS LOCATION: -/ C.Y'Ay C*e7g_y/L5 MAILINGADDRESS: 7-1 CW'N WliTtAvf Mail To: TELEPHONE NUMBER: Lla;O 2,6 3 4 Board of Health CONTACT PERSON: �/- e- 7- �4-3 S �� Town of Barnstable P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: soe 3.'Le 4/ 4/ Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: �-✓�� TELEPHONE: ._ LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids w p- oc" -sm e- (dry cleaners) so C v,f A, �f Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS __..__....._._.._... ...._..... .__.__...._._.._._ Town of lid rnsta le >P# Department of Health,Safety,and Environmental Services 117 Public Health Division Date Q� 367 Main Street,Hyannis MA 02601 S eAaNSMAOM + 'r 0. Date Scheduled 6// - ��d- (�,,11 n to Time Fee Pd. v -G�' _. Soil Suitability Assessment for S ge Disposr> Performed By: @H t^,R. •. Witnessed By: ioi i i sS%i i!!i i?? :#i ?i:i:i ai''•'i3 ::ii":":`;:. ",' - ::.....:.:.::.:::::,..,y...,,.:; ...:.,:.::.::: •:.:;.::; �y..::.. :,:.;.`.::i:i 3i%i°3 i%231%%"r: i 'i2`;' .......................:::.:.:::::.::.:.:::::...:::::::::.:::.::::.:::.::::::::.:.:::::::;;;;.<.::.:.:;;:;:.::;::;;:::;<.;;:.;;;:;.>;;:.::.;;; >:.;::::>::::;:......:::;::»:>: Location Address I / Owner's Name qcL►— CO'f^� Address / �+ Assessor's Map/Parcel: ��/6 Engineer's Na Me, U � NEW-CONSTRUCTION REPAIR TelephoneSd Land Use TfIJ�'_.1'td�_l Slopes(%) C/ Surface Stones Distances from: Open Water Body R Possible Wet Area.3rlo ft Drinking Water Well ft Drainage Way / R Properly Line Z5 tl Other f SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) r ,t Parent material(geologic) lao Depth to Bedrock Depth to Groundwater: Standing Water in Bole: 1V��� Weeping from Pit face Estimated Seasonal High Groundwater #% Y:<s»`>:::`•::;»::>.y.�:::�...t.!.y..t,.�..1:....:.:;.....:.•..:::.......:.:.:.....:.......::....:................ .::.....:,,,:;;. ••::•s:•x••>::.........:..,.....,;....:..,,..,,.........:...,,:.....,t;;....:.,::...:;.;:.;;:.::.::.>::......... ::.:.:............. ::.>;:•::•... :.:...::::::::::::::.::::::::::::::.::::::.::. ::::.::.:::.::.::::::.:::::.::.:;:::::::......::::.:::.::::::::: .::;::.::.::::.::::.::.:.:.:::.::.:::.::....:::::::.. Method used: ................... Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment fl. Index Well# Reading Date:" Index Well level Adj.factor Adj.Groundwater Level t2. . S tD•... ...mom e» Observation Hole# Time at 9" N Depth of Perc / Time at 6" Start Pre-soak Time© t G Time(9"-6") End Pre-soak e Rate Min./inch Site Suitability Assessment: Site Passed Sitc failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant . ----- Depth from soil Horizon Soil Texture Soil C010T Soil d e Surrace 011.) (USDA) (Munsell) Mottling (Structure,Stories,Boulderes. Depth ft!m Soil Horizon Soil Texture Soil Color t ier Surface (USDA) (Munscil) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel) 10 Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulderes. Consistency,%Gravel) Depth from Soil Horizon olfTe'X'iilre' Soil C010'r soil Othcr Surrace(in.) (Munsell) Mottling (Structure,Stones,Boulderes. Flood Insurance Rate Map: ' . ` ` . Above 00year flo odboundary wv__ Ym�_ � Within 5ou year boundary No Ym___ Within lOo year flood boundary Nv Yun____ Depth of Naturally Occurring Pervious Material Does o1 least four feet of naturally occurring per i \ex|otinn\|oru000hoomcdthrnouhout the area proposed for the soil uhuuqzdnn oyutomY l[unt,what io the depth of naturally occurring pervious material? __________ Certification l certify that l have passed the soil evaluator examination approved by the Department of8ovironmentul Protection undthut the above analysis was porbonnodhymm consistent with the required training,expertise and experience described in 3 10 CMR 15.017. Signature Date 0 �r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information ' �� X Important: When filling out 1. Property Information: forms on the computer, use 71 CAPA CARLETON ROAD only the tab key Property Address to move your WALLACE ASSIS cursor-do not Owner's Name use the return key. SAM E Owner's Address L COTUIT I MA 02635 City/Town State Zip Code Date of Inspection: 3-21-07Date 2. Inspector: MICHAEL A. BURNIE Name of Inspector. DAVID J. BURNIE &SONS SEPTIC SERVICES blue water holding corp. Company Name 105 FERNDOC ST UNIT A Company Address ci i HYANNIS MA ^02601 City/Town State 508-775-0139 Telephone Number B. Certification I certify that I have personE Ily 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. -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 Ev luation by the Local Approving Authority 3-21-07 Inspector's Signature Date The system inspector hall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)with n 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 appropria:e 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. title5 2006 blank.doc•03/2006 Titl Official Inspection Eprm:Subsurface Sewage Disposal System.• Page 1 of 16 1 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4 H SV•y`• _ B. Certification (cont.) 71 CAPT. CARLETONS RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E I 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain:. F title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 r Commonwealth of assachusetts Title 5 Off cial Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM 0``0 B. Certification (cont.) 71 CAPT. CARLETO S RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pip (s)are replaced ❑ obstructior is removed ❑ distributior box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass in pection if(with approval of the Board of Health): ❑ broken pip (s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluatior is Required by the Board of Health: ❑ Conditions exist wh'ch 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 pas 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 o privy is within 50 feet of a surface water ❑ Cesspool o privy is within 50 feet of a bordering vegetated wetland or a salt marsh I title5_2006_blank.doc 03/2006 T Official Inspection Form:.Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments .Subsurface Sewage Disposal System Form B. Certification (cont.) 71 CAPT. CARLETONS RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a,septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:-Subsurface Sewage Disposal System ' (� Page 4 of 16 r Commonwealth of assachusetts Title 5 Off cial Inspection Form ° Not for Voluntary A essments Subsurface Sewage Disposal System Form M B. Certification (cont.) 71 CAPT. CARLETO S RD. Property Address COTUIT MA 02635 Citylrown State ZipCode WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection D)System Failure.Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® E ackup of sewage into facility or system component due to overloaded or ogged SAS or cesspool ❑ ® I ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® tatic liquid level in the distribution box above outlet invert due to an overloaded o clogged SAS or cesspool ❑ ® L quid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pi,pe(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. ❑ ® A ly portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Arly portion of a cesspool or privy is less than 100 feet but greater than 50 feet fr m a private water supply well with no acceptable water quality analysis. [This s stem passes if the well water analysis, performed at a DEP certified la boratory,for fecal coliform bacteria indicates absent and the presence o ammonia.nitrogen and nitrate nitrogen is equal to or less than 5 ppm, p ovided that no other failure criteria are triggered.A copy of the analysis o chain of custody must be attached to this form.] ❑ ® Tie system is a cesspool serving a facility with a design flow of 2000gpd- 1 ,000gpd. . Yes No ❑ ® T ie system fails. I have determined that one or more of the above failure c teria exist as described in 310 CMR 15.303, therefore the system fails. The s stem owner should contact the Board of Health to determine what will be necessary to correct the failure. title5_2006_blank.doc 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page.5of16 r Commonwealth of assachusetts N = v Title 5 Off cial Inspection Form m ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 71 CAPT. CARLETON S RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owners Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section.D YES NO ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® t e system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have-answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a si nificant threat under Section E or failed under Section D sha11 upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. title5_2006_blank,doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System y , (� Page 6 of 16 Y Commonwealth of Mi issachusetts Title 5 Offi ial Inspection Form Not for Voluntary As essments Subsurface. Sewage 0 sposal System Form C. Checklist 71 CAPT.CARLETON RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection Check if the following t ave been done. You must indicate"yes"or"no"as to each of the following: YES NO ® ❑ PLnping information was provided by the owner, occupant, or Board of Health ❑ ® W re any of the system components pumped out in the previous two weeks? ® ❑ He i s the system received normal flows in the previous two week period? ❑ ® Hai ie large volumes of water been introduced to the system recently or as part of thi inspection? ® W re as built plans of the system obtained and examined? (If they were not av ilable note as N/A) ® ❑ W s the facility or dwelling inspected for signs of sewage back up? ® ❑ W s the site inspected for signs of break out? �icliclir� ® ❑ W are all system components,*mMkjftthe SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank ins, ected for the condition of the baffles or tees, material of construction, dii r ensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with iii c rmation on the proper maintenance of subsurface sewage disposal systems? T size and location of the Soil Absorption System(SAS)on the site has b len determined based on: ® El E i ting information. For example, a plan at the Board of Health. ❑ ® DIt rmined in the field (if any of the failure criteria related to Part C is at issue adproximation of distance is unacceptable) [310 CMR 15.302(5)] title5_2006_blank.doe 03/2006 Title icial Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 r Commonwealth of M ssachusetts Title 5 Offi�ial . Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form '4M Sveya. D. System.Informition 71 CAPT. CARLETON$ RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(Resign): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): UNKNOWN 4 Number of current resi 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 06-421.9 GPD Water meter readings, if available (last 2 years usage (gpd)): 05-564.3 GPD Sump pump? ❑ Yes ® No CURRENT Last date of occupancy: Date Commercial/Industri-I Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No .Water meter readings, if available: Last date of occupancy/use: Date Other(describe): titles 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Di posal System Form 'J^M D. System Inform ion (cont.) 71 CAPT. CARLETON RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: 7-6-06,8-2-00,5-19-00,7-27-00 PER OWNER GALLONS UNKNOWN Was system pumped a part of the inspection? ❑ Yes ® No If yes, volume pumped. gallons How was quantity pum ed determined? Reason for pumping: . Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overfl w cesspool ❑ Privy ❑ Share 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: 7+YEARS PER PERMIT DATED 6-22-00 Were sewage odors ditected when arriving at the site? El Yes ® No 9 9 title5_2006_blank.doc.•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Dirposal System form Seey`e D. System Information (cont.) 71 CAPT. CARLETON: RD. —_ Property Address COTUIT MA 02635 Cityrrown State Zip Code WALLACE ASSIS 3-21-07 Owner's Name ( Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private mater supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate o site plan): Depth below grade: 15" p g feet Material of constructio : ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list a e: g years Is age confirmed by a certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate)_ - - - - -Dimensions: -------------------- ------------- --------------------------------------------------1000 GALLONS 6" Sludge depth: Distance from top of sl idge to bottom of outlet tee or baffle Scum thickness 3 Distance from top of scum to top of outlet tee or baffle Distance from bottom L scum to bottom of outlet tee or baffle How were dimensions determined? title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form - Not for Voluntary Assessments A o Subsurface Sewage Disposal System Form iG�M SVey`v D. System Inform tion (cont.) 71 CAPT. CARLETON4 RD. — Property Address COTUIT 1 MA 02635 Cityrrown State Zip Code WALLACE AS.SIS 3-21-07 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related iio outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete C11 metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle -- Distance from bottom If scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumpi g 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 constructio v ❑ concrete ] metal ❑ fiberglass ❑ polyethylene ❑ other(explain): tifle5_2006_blank.doc•03/2006 Title 55 Official Inspection Form:Subsurface Sewage Disposal System- /%/�'a' , Page 11 of 16 Commonwealth of M ssachusetts . Title 5 Offi�ial Inspection Form {{ a Not for Voluntary As$essments Subsurface Sewage Disposal System Form M D. System Inform6tion (cont.) 71 CAPT. CARLETONL RD. Property Address . COTUIT ' MA 02635 Cityrrown State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection Tight or Holding Tani,(cunt.) 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 1 f alarm and float switches, etc.): "Attach co of current pumping contract(required). Is copy attached? ❑ Yes ❑ No copy P P 9 Distribution Box(if p esent must be opened)(locate on site plan): Depth of liquid level agove outlet invert 011 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.): THE D-BOX WAS AT 1N01RMAL LEVEL AND SHOWED NO EVIDENCE OF SOLIDS CARRYOVER Pump Chamber(locate on site plan): Pumps in working ord filer: ❑ Yes ❑ No. Alarms in working ord r: ❑ Yes ❑ No title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of M ssachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 71 CAPT. CARLETON RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection Comments(note condition.of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, exp ain why: Type: ❑ leaching pits number: ❑ leaching chambers number: 2-500 GALLON ® leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflo�cesspool number: ❑ innovative/alternative system T e/name of technology: 9Y: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): THE LEACHING GAL ERIES WERE IN PROPER WORKING CONDITION AND SHOWED NO SIGNS OF FAILURE AT TIME OF INSPECTION. title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form T5 Not for Voluntary Assessments Subsurface Sewage. Disposal System Form �M D. System Information (cont.) 71 CAPT. CARLETONI RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to nlet invert Depth of solids layer . Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): aitle5 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System ����� Page 14 of 16 Commonwealth of Me ssachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 71 CAPT. CARLETONI RD. Property Address COTUIT MA 02635 CityrFown State Zip Code WALLACE ASSIS 3-21-07 Owner's Name Date of Inspection Sketch Of Sewage Dis�osal System: Provide a sketch of the sewage disposal system including ties to at least two permanelnt reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �l title5_2006_blank.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 �.s �, p a W u u i Commonwealth of Massachusetts Title 5 Offi ial Inspection Form Not for Voluntary Assessments Subsurface Sewage D sposal System Form GSM iV• D. System Information (cont.) 71 CAPT. CARLETONI RD. Property Address COTUIT MA 02635 City/Town State Zip Code WALLACE ASSIS ' 3-21-07 Owners Name Date of Inspection Site Exam: Slope ^6 Surface water AJV Check cellar .0.y Shallow wells ,vim Estimated depth to gro nd water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Y 9 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators installers- attach documentation ® Accessed USGS database -explain: SDW-253 1 ZONE C 3-4 LEVEL 48.3 ADJUSTMENT=3.3' You must describe how 9 you established the high round water elevation: Y 9 SEE ATTACHED title5_2006_blank.doc•03/20Q'6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �� Page 16 of 16 I � n. .,-�.;,r tt:" t•-�..Y•"rY•r-�'tyvw.: �.. �. _ . .r ��'. r4� .. .. . Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: CS 04 P7q%N`t11`19 J BUSINESS LOCATION: C/VAI 61fle7oy^5 , �Q MAILINGADDRESS: Mail To: TELEPHONE NUMBER: Board of Health �� L�� -�6 3 � Town of Barnstable CONTACT PERSON ,.....1/-gGL S P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: doe 3,9-& Hyannis, MA 02601 TYPE OF BUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) 21 lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids w 60 (dry cleaners) 1 Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Health Complaints 05-Nov-99 Time: 3:37:10 PM Date: 11/5/99 Complaint Number: 2134 Referred To: GLEN HARRINGTON Taken By: LS Complaint Type: ARTICLE X- FOOD Article X Detail: Business Name: Number: 71 Street: CAPT. CARLTON RD. Village: COTUIT Assessors Map_Parcel: Complaint Description: CATERING SERVICE IS BEING RUN OUT OF THE HOUSE WITH NO PERMIT. Actions Taken/Results: Investigation Date: Investigation Time: 110 Cl/� rrw la,� t y e c fiL�u. c�.la e} 1 Y No..---..2.......-•---. Fly$.............................. THE COMMONWEALTH OF-MASSACHUSETTS - i BOARD OF t-aEALT Apphratioo -for 'Uispmat Works Tow5trortioo Vierutit Application is hereby'made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Dis osal Syst at: ,.....---- .•ZZ............. ......fir .... ............... o tion- dr 1wr Lot �( . Owner Address a .�.- .....-------•-•-•--- ----- ---------------- Installer Address ee,, U Type of Building Size Lot...o _ lV;KSq. feet �' .� Dwelling—No. of Bedrooms---_�---------------------------------Expansion Attic ( ) Garbage Grinder W Pa- Other—Type of Building ✓ --_____.-___ No. of persons--------�................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------••------- -- - W Design Flow...........t�fo.........................gallons per person per day. Total dai� flow------J 30....----------------------gallons. WSeptic Tank—Liquid capacity,/l�-_gallons Length___________ Width._......-_ Diameter---------------- Depth. _�--.----- x Disposal Trench—No..................... Width................---- Total Length.................... Total leaching area----..-._---..._.--_sq. ft. Seepage Pit No......../.......... Diameter.......F......... Depth below t' '" �G "1 .....4_� .__} tal leaching area._d60--_---sq. ft. z Other Distribution box ( ) Dosing to ( ) m Y"/J- 77 Percolation Test Results Performed by._._._. - _<� cLr^1 __ �._._ �,x/.f?Y_......__ Date------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit--------------_..... Depth to ground water.._-__._.----.---.--_- (_, Test Pit No. 2................minutes per inch Depth of Test Pit...----------------- Depth to ground water------------------------ Ix ------------------------------ 1<----- --- Descriptign/of Soil.--------- -L----- --��------ 1 `----�----- w �� (�,, /� «s.�sC .-..�----&----� W UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------• ------- -------- ------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been) s ed y the board h th. Slgne a----------------------- ...X-_cZFm Date Application Approved By--------- -------s 7 Date Application Disapproved for the following reasons:-------•----------------•-------•---•-•-----•----•------------------------••--•-----•-------•------------/------ --•••-•--•--........-••-•--••------------•...................••--•-------.--.----•--•--••----•-•-----•--•.......---------••----------------------•-----•- •---------------•-••----------••--------------- Date Permit No................................---•------•---•--------- Issued.---..L..^..1... . --7-7--••-••••-- Date - ---- - - ----- --- ! e- ' r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6t - Apli iration -fur Vaivoiitti Workii Tomitrurtitf Prrutit . Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t , a T -•--� ' o� �� ----------- -c7...... IF..-- a .l~__- .� ------....-•- . --- o, tion dr� or Lot No. 04 W / Owner I Address �_ -et"----_ ...... ------ --•--••-----------•--•--••-----------•-•-•- -Installer -� i tt�,� Addess U.�,�,__Ty,Pe,of�Building Si erLot_..a__1�V. X_Sq. feet Dwelling—No. of Bedrooms_--_,—?_.!------------------------------Expansion Attic ( ) Garbage-/Grinder Other—Type of Building a YP g ... No. of persons.---:--�---------------- Showers ( ) —;Cafeteria Otherfixtures ----- ------------------------------------------------- -------------------•---- WDesign Flow..._.._.__............�O-------__------------gallons per pet-son per day. Total daily flow------L.�Q________--_______ -__-_.._gallons. P; Septic T,.nk+-Liquid capacityl�__gallons, Length___�_______ Width--� -----_.- Diameter__-__-_--- ___ Dep�,k__.fa��-_---- Disposal Trench—No_ ____________________ ��/idth._.___,y.:;:._____. Total Length_________- __..___-_ Total leaching area-------------. -----sq. ft. Seepage Pit No--------/---------- Diameter------g Depth below inl t_.___ 5� ____�glTotal leaching ------sq. ft. z Other Distribution box ( ;) " Dosing to k -77 '-' Percolation Test Results Performed by-.__-__ . -i �- ;�c�_._ __._____ _'. ---------------- Test a f J��. ' �1 -------:_ Date----------------------=-- i Pat No. L_______________mimites per inch Depth of "Pest Pit................. Depth to ground water------------------------ (� Test Pit No. 2---------_......minutes per inch Depth of Test Pit......:.............. Depth to ground water------------------------ -------------------------------- ' J ---- -------------•• -• t O Description of Soil- .....T ---------- ------- W x ------- -------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable._ ____-___--__._._____::;_: ----------- ------------------------------------------- - Agreement41) i- The undersigned agrees to install the -a-foredescribed Individual Sewage-Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place_ the system in operation until a Certificate of Compliance has been is's ed y the board of h alth.'. Signed f dC- - ------------ ---- ----- =D _... 7 Application A ro. d B PP PP Y •-•------ Date Application Disapproved-for he following reasons: "`_ _____________________ ______________ .---•-•------•---•-------••----------------•-•---•--------•----r -•----•-----------------•------------••---•-----•------------------•--=-----------------------•-------•----•---- ,A r Date 7 Permit No. = :' x: Issued.------ = / ._�--•-=••••---••--•••--•-- 3 ' a Date THE COMMONWEALTH OF MASSACHUSETTS.'"% .. M, BOARD :'C�•F EALTH # ,rr, ,, ..OF.... . ' r �'� ........................ I :........... A ,, x, !�r.-der#i� r�tp � f��rnt�iittnr�e THS TO CERT1 / h tath"; fndivi 1 age isposal System constructed ( or Repaired-C.. ... .......... ....C........... ---------------- ( ) Installer ?" at has been installed in accordance with he rovisions of : e-`XYof The State'`Sanitary Code as:described in the application for Disposal Wori<s Construction termit�N .....2:!/!-______________ dated____$,- �^_�_��._____________ THE ISSUANCE OF.4HIS IGERTIFlCATE S44AL'!;NOT BE CONSTR ® AS A GUARANTEE THAT THE SYSTEM Y I L.FUNCTION SATISFACTORY. . <x t "i / %: DATE ........r ------ === ------- :.Inspecfor-- ---�_ r. ' A. COMMONWEALTH OF MASSACHU..SETTS r" t �•4.a BbAR`D F HEA TH No. FEE Fl Permission boreby grant d""`: _ - - . ........... .. ..................... __ ____ to Construc or R it ianr tdual Sewa D osal Syst at "..�.. . C t ate• , �' f R S reet as shown on the application for Disposal Works Construction ,';Per of._. _.__ ""_ <ted___%07`13_A -- --- s.• Board of Health t DATlsW FORM 1255 HOBBS & WARREN. INC:. PUBLISHERS - - L,a.h G H PIT' 11000 GAt. SEPTI c, T�►y►_ (� { o ? 4.J v N E`f^jf Fo\ 4 p. co 0 © 4-(,''� r l_OT �N tr 2 ! mo o. 00 3D da_xTLG C.E{ZT%r-%ELD Pl►bT *lo ?�C�4tl Stl LOCATIO" CC)7 V 1 T' D � 16CAL 1 N= 30PT VA>T1= 1 CMSZTIPI( T"AT' TNT �oUN�A��oNS�-1 ►J -4�.1 RilFcc��►.i�E Wv-_e E aN GOMPLYS W vr" LOT 3 f AWra SET12ArV VE_4vilZGAAe 1TS of THE "toWU of k DATE 5 17 B/�XTCtZ 1J�t'E 14.lG_ REGIS"[t3c�U 1-A�.tp SuevtYoczS '( "I'S V LA W (S v OT EASED OW AN OST6iZVtt_LG o Mt asS, IFJSf�Qcl•tnE�JT �,vevcY TNc- oF�ScTS 5�aow�la APPt_l CA,"-T- QETEIZ Co �- `—t rt5 WOT 6L- u5Et' TO DcCTC-.etilt�l� lOT l.�N�S LO•CATION 'J� SEWAGE PERMIT NO. OlfVI LIIAG E 11 f Co 7 ' r �L4-a. C1a�� INSTALLER'S NAME & ADDRESS A co -Z 7 3' � 13 BUILDER OR OWNER DATE PERMIT ISSUED _-� � T DATE COMPLIANCE ISSUED I }�i `� �� t�� Y �'+ �33 V ' ,r kA . � py • e �� l / � 1 �. � � , � e � ` � , �2� . .� ,^ _ � x `� ,. _ a � . � ._ ••1. .._ �' �i 't'� .� .�