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0017 DOGWOOD LANE - Health
17 Dogwood Lane f Cotuit P A = 040 074 TOWN OF BARNSTABLE LOCATION („Lt1�U '� SEWAGE# .%j 7,e VILLAGE ASSESSOR'S MAPn&PARCEL ,O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY A�-7 Aoe,4> v LEACHING FACILITY-(type)C;2 600 CAL 6 if> (size -J�_ • NO.OF BEDROOMS OWNER M f& L 0 a ,f PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: ,,Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility Feet FURNISHED BY a �l y L � � w T+D'W1��lF BARNSTABLE tb I,�4Cair t� �t j P+SSESa" &A. i1�5'ii'AL1, Xt'S NA11tIE dt P1ROME NO rw L�AICIllNG1F+AC�TTY' .(�$) r �UILIDEi�aR cw raE� PERMI DAii`L+.. ,, CoivAb .lANG �� ,...._ .... .i VMS OW k�estnnae Batv�e�la�a , Nl�xunu.Acljustad kOUR�lw#'A bletothe>��ttotnoGX�ea;hin�t�ciUty Lees gi9v8a� l or.Supply wa!<ls �d Y.ed�.Sti�gacdutY t ►Y !fll9s�xCst g ot1 seta a�wlthiin'.2p0 Petit o�l��echi+u�f��islt}�) :'-: &scat. Ecili�c�Ti�lt$and Md.lreacfliln facility(1 au�y wetly�d5 exist sec tvD9laitl'10(1�(.q' ICACI�Itts�aili ) rlf�` Lr/LI: ct, II3 0� I, C2 A-3- 33 ` TOWN.OF BARNSTABLE LOCATION. 0 SEWAGE # V11.LAGE C ft I f, ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILLr Y: (type) ' (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If an wetlands exist within 300 feet of leaching facility) ��22 � g Feet Furnished by �( V� ���L� o � `Q C' y �� A Ty10N S E W A G E PE CIVIT p0. VILLAGE ODD o°y IHSTA LLER'S DAME & ADDRESS U I L D E R OR OWNER DATE PERMIT ISSUED � I f6 X 9 Q'ATE COMPLIANCE ISSUED- . ---�- • 1 . e T �`� h No.p01 6,3-,:c Fee ®� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF,BARNSTABLE, MASSACHUSETTS YeS RppliLation for M_I.st oral .6pstem Construrtiun Permit Application for a Permit to Construct( ) Repair grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./�? ;f� U�O(� ,f �(/� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel C��U© 11 AVl/6?5 Installer's Name,Address,and Tel.No. 4(//11/� /�d(�ypd1` Designer's Name,Address,and Tel.-No.�GC� —� Type of Building: Dwelling No.of Bedrooms Lot Size °� 7dO sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 33 D, ® $1 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �� ���0 Type of S.A.S. !,UD ARO /4-5 Description of Soil C, Nature of Repairs or Alterations(Answer when applicable) /��� /� /j U 15k: C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ,AQ 1:2 7�rt Date Issued QL b 3 7 No. CJ`�' 3 O Fee / oo THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes JtYlcatl0n for )NS,posal *pstem Construction Permit Application for a Permit to Construct( ) Repair(L)'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or.Lot No Mf �65W0O0 A,0/(a, Owner's Name,Address,and Tel.No. Assessor's Ma /Parcel cam"«,�/T p S/C7 _ Installer's Name,Address,and Tel.No. (,///��/G�r!/��j � Designer's Name,Address,and Tel.No. 5CCO 6 n 7i&C, ��. fly`rt?� a �X o/ i,SS_ ceo Ry�a�r' Type of Building: Dwelling No.of Bedrooms Lot Size 4)o"2 21gQ sq.ft. Garbage Grinder( ) Other Type of Building , t No.of Persons Showers( ) Cafeteria( ) Other Fixtures j Design Flow(min.required) �U gpd Design flow provided ���. U gpd Plan Date Number of sheets Revision Date, Title _ Size of Septic Tank Type of S.A.S. / j Description of Soil f h�v� �Q l /—i 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 Certificate of Compliance has been issued by this Board of Health. ' Signed r� Date Application Approved by Date Application Disapproved by Date ti for the following reasons RF Permit No. Q `� Date Issued Q 13 /7 - -------- ------------- - ----- ----- ----- - ---------------------- ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by at / / G`CUj/� /�/ �J/ has been constructed in accordance with the provisions s�of Title 5 and the for Disposal-System Construction Permit No.a0/7—G 3dated 3 -2 Installer /.`l� �t9 � � Designer #bedrooms Approved design flow f 17,?.�� gpd The issuance of this permit shall .of be construed as a guarantee that the system will funMy signed. Date )I l� 1f -7 Inspector �l 1A� PS --------------------- ----------------------------------------------------------------------+----�------ No. �I _ 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal 6pstem ConstrULtion permit Permission is hereby granted to Construct( ) Repair(!i� Upgrade( ) Abandon( ) System located at /�� / —& C_aZZ//T— and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must a compledd within three years of the date of this pe Date f Approved Town of Barnstable- °Ft►+E r°,f� Regulatory Services c Richard V,Seah,Interim birccior AAANSTADLE MASS. Public-Health Division A'Fo ,ip Thomas McKean,Director 100 Main S.trect,Hyannis,MA 112601 0-ffice; 50.3-862-4644 rax: 508-790-004 Installer&Designer Certification,Form `Date: `ls Jl�? Sewage Permit#�O// Assessor's lap\Pareel 40/74 Designer: David D. Coughanowr RS Installer: I/�/�i� Address- 155 George R 'der Rd South 9 Y Address: � Chatham, MA 02633 On —/6 �y was issued a permit to install a (date) (in taller) septic system Alt 17 Dogwood Lane based tin a.design drawn by (address) David D.Coughanowr, R.S. dated dec. 13, 2016 (designer) X 1 certify that-tbc septic,rsysteri referenced above was installed substantiaily according to the design, which inay include minor approved tha iges skli as lateral relocatiob of the - di'su ibution box an . rr septic ttii k. Strip oitt (IC required) was iiispected and flie.s6ils were fowid atisfactory` I testify`that the septic system refe'renec l above was installed :with majr i cha tgcs (i:c; greater:than 1:0.' lateral relocation of the SAS or:any, vertical relocation o- ny component of the Septic system)but m;accordance wrth State &Local Regulations: P-lan rcvtsion•or certified as-litrilt:by des;rgrier to follow:: Strip out (if rccluircd) was inspcc"td iind the s0)IS were.found ,it isfactory I;i ei tify that file system referenced above was con"strt cted in compliance 4iih the tefts of the AA approval IMers(if applicable) �A 0 F,4)q ,0/ ' Cam- DAVID Wmr- ImWler.'s Si iiu ' g GOUGHAt�0Y1R COU:GHANOWIZ i 1"093� F ' CAS F� U Et75E (l�eSi rler;S Si itat tire)' nGr'S seal. PLEASE RETURN,TO 'BARNSTABLE PUBLIC 'HEALTH'DIVISION. CERTIFICATE OF COMPLIANCE, WILL INOT, BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT.CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK.YOU. , ! � t Q:-XScptiODcsigner Gctu6ca ion 1 onii Rcv s-1�1 l3."<loc _ F 7 p «�f� LEGEND L� �2 O T a 1 SEPTIC COMPONENTS AREA = 22700 sf+— EXISTING PLAN BOOK 282 PAGE 27 --_J 1000 GAL i SEPTIC TANK 1 A55R MAP 40 PCL 74 1 EXISTING 15 in LEACH PIT/ 52 1 - *OAK \ O CESSPOOL GARB DISTRIBUTION BOX 0 G R 51 TEST PIT *15 T OWED / OAK 1 15 in OAK 15 in \ \ ® \ *OAK \ II \ IS O in ���® ® AK IS)in OAK 2 \ *OAK 15 in _ ® 0 PROPOSED SOIL ABSORPTION 1 # ' SYSTEM 00 O O / N —SEE DETAIL \ '3- ON BACK \ \� 51 MINIMAL GRADING t6 �-d PROPOSED O ^n CN THIS IS A \ � ®�®�� \Z COLOR 3 PLAN USE COLOR PLAN ONLYFOR INSTALLATION FULL DETAIL IS BEST �I Oho:® VIEWED IN �� i G ° ° / FULL COLOR J� C . 9 52 ° \ G � / ' U T§L a T§E I G V WATER LINE WATER GATE 0 . C. „ GAS LINES OVERHEAD WIRE 0{FI \ / 5 O� �EMEN� U UTILITY \ �2 ` PA POLE DRAIN (o)�® O EO� OLAN �c H �NSTALE G1S DATA"f/� / v SCALE: I in = 20 f t . ELEVATION 1/ / go 0 20 40 5 5.2 4 TOP OF FOUND P��O� 0 10 2 0 PRINT ON 8-112 x 14 .in j PAPER FOR PROPER SCALE SCp OCa ((U��IN���jjaa�MM� AT FLOOR PLAN - . -- O C u (C. CW° j i -- E C��� � �� BED BATH KITCHEN/ W �I ROOM DINING '0 � Q BED BEDM� LIVING 0 . ROOM IRO ROOM OF �(N MASs9 N OF MgSs — -- - ---- N DAVID CyG � q�ti v 9 D. �, DADVID � Oo�i E SEWAGE DISPOSAL v -+ COUGHANOWR a COUGHANOWR G SYSTEM PLAN No. 1093 No. 461 -TO SERVE EXISTING DWELLING MTGLO m � � O F DRIVE sA so/Z 0Pt L INVESTORS LP �I 9 a PINE V1EW�MOUIN RD �� �� DWNER(S) OF RECORD FA NOT RESQG01 17 DOGWOOD LANE ROUtE ZS To COTUIT, MA 155 Goo Ryder Rd S SCALE THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE y PROPERTY ADDRESS COTLIIT, MA SEPTIC SYSTEM DEPICTED ON IT. FOR ANY OTHER CHANGES Chatham, MA 02633 TO THE PROPERTY INCLUDING PLACEMENT OF ADDITIONS.SHEDS FENCES ED TO DQVICICOU[?QHOtmQILCOm DATE. DECEMBER 13, 2016 L O C U S - M A P CONSULT W THOARMASISACH MMING SETTTSS REGIIS ERED I LAND V IS URV OR. jj 508 364-0894 E ii2 �De ErE-4119 !ABODE SOo0� TEST u L OO PERC# 52256ER 13, 2016 D E S IANN (CALCULATION , SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE *461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD WITNESSED BY: DAVID STANTON. HEALTH DEPT. TEST PIT I NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS PERC AT 60 in — 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOUND STRUCTURAL CONDITION. IF NOT. INSTALL INCHES HORIZON TEXTURE (MUNSELL) MOTTLES NEW 1500 GALLON SEPTIC TANK. 52.00 0-4 O SANDY LOAM 10 YR 2/1 NONE FRIABLE DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 4-6 E LOAMY SAND 10 YR 4I1 NONE FRIABLE SCUIL ABS�ORBTION SYSTEM: 6-14 A LOAMY SAND 10 YR 3/3 NONE FRIABLE 49.00 14-36 B LOAMY SAND 10 YR 4/6 NONE LOOSE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 36-138 C MEDIUM SAND 10 YR 5/4 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 40.50 PER INCH =C 0.74 GALLONS PER DAY PER SQUARE FOOT. NO GROUNDWATER ENCOUNTERED THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY TEST PIT 2 PERC AT 60 In - 2 MIN/INCH IN C SOILS DEPICTED BELOW CAN.LEACH: ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER '. INCHES HORIZON TEXTURE (MUNSELL) MOTTLES BOTTOM AREA = (24 x 12.5) = 300 sq. ft. 51.80 0-6 O SANDY LOAM 10 YR 2/2 NONE FRIABLE SIDEWALL AREA = (24+24+12.5+12.5)x2 =146 so. ft. 6-7 E LOAMY SAND 10 YR 4/1 NONE FRIABLE TOTAL AREA = 446 sq. ft. 7-14 A LOAMY AND 10 YR 3l _S 3 NONE FRIABLE FLOW CAPACITY = 0.74 x 446 - 330.04 gal/day 48.97 14-34 B LOAMY SAND 10 YR 5/6 NONE LOOSE 34-138 C MEDIUM SAND 10 YR 5/4 NONE LOOSE INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED 40.30 BELOW. FLOW CAPACITY = 330.04 gal/dog WHICH EXCEEDS THE 330 gal/dog REQUIRED FOR A THREE BEDROOM DESIGN. " 1000000 �,gLLON��f @SEPTIC TAM - .', A eORrT1ON TANK TO BE PUMPED DRY AT TIME OF INSTALLATION `y M T E M C�o� 't p o�,9QGIQ'� AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. Cm sw NOW M eelsl= REPLACE WITH A NEW DRYWELL 24.0 ft 1 in ( 1500 GALLON TANK UNIT TAPER IF CRACKED, ROTTED � -' CR 0 THER WISE OMPROMISED. 0 CID 9NOT I co Z l -- - - Ln SC TO c E STONE 3.5 ft 8.5 ft 8.S ft 3.5 ft i 8 ft-6 in A 500 GALLON DRYW ELL DIMENSIONS & DETAIL INSTALL ONE INSPECTION INLET OUTLET RISER TO WITHIN THREE COVER COVER USE INCHES OF FINAL GRADE —- - H-10 & INDICATE LOCATION 3'IN DROP ON AS-BUILT -► � FLOW LINE UNIT FROM - 0' 33 BUILDING 10 in 14 TO __ t ~pp in D-BOX 48 in L o 000'on ❑ 000'p, LIQUID GAS moo o D:p ., LEVEL BAFFLE 5 1p2 in b in STONE BASE IF NEW CROSS SECTION VIEW SEPARATION BETWEEN INLET & OUTLET INSTALL AN APPROVED GEOTEXTILE TEES NO LESS THAN LIQUID DEPTH FABRIC OVER STONE CROSS SECTION VIEW D I S T R 1 : U T 1 O N 28 3/4 in TO 24 In 3/4 TO ►% 1-1/2 in GRAVEL ® EFFECTIVE® 1-1/2 in GRAVEL" in DEPTHmom fn a 46 in 58 in 46 in -- - 150 in ' 12 In - - - C MIN INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE i 3 —► N STARTING WORK. Ln FROM —� -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM n1 TANK to TO O REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC u;b ^ SAS CODE (310 CMR 15). O INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. b in STONE BASE ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES & APPLIANCES, AND PERIODIC 21 in ?,� CROSS SECTION VIEW PUMPING OF THE SEPTIC TANK. S -SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. E7 TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE SCH. 40 PVC I EL = 55.24 +- 6 in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 7 52.00 In EXISTNG USE H-20 TEE 49.0 MAX EXISTING 1000 GALLON j � o.Aoo PRECAST w00%°odPq p .DRYWELL o •o�Qo as TANK 48.38 040 °o bao a°oo 0 0 EXISTING in REFER TO DETAIL BOX STONE S0L ABSSORPTT ON + � 48.55 BASE 48.25 EXISTING 6 /n STONE BASE IF NEW SYSTEM -REFER TO p 16 ft 5-12 ft DETAIL BOX ° NO GROUNDWATER BELOW 46.25 MOTTLING OBSERVED _ 40.30 SEWAGE DISPOSAL SYSTEM PLAN 1 17 DOGWOOD LANE COTUIT, MA DECEMBER 13. 2016 ETE-4119 PG 2/2 Town of Barnstable P# /5 a a� Departitnent of Regulatory Services i „"Ne1•,,MA 1 Public Health Division Date_ v 3! �� MARS. a63D 200 Main Street,Hyannis MA 02601 Q Date Scheduled 6 Time /I JH lf^ Fee Pd._ Soil Suitability Asnsessment for"Se ge isposal' Performed-By:_Oqy i 6k D . (O i)0GI,Y Wyr Witnessed By:4L-✓% �, �S LOCATION&.GENERAL INFORMATION rr++ Location Address 17 ttwaxt G Owner's Name � (-a y��Irl i Address tJ1 D e&,P-;t t. G k. Assessor's Ma /Parcel: _ uI Pr( � B��L1A/7d�✓�' 4�! Engineer s Nampe� NEW CONSTRUMON REPAIR V Telephone# Lund Use- 5lopes(96) v Surface Stones 0 h Distances from: Open Water Body 100 * _ft Possible Wet Area /�{,b6'} ft Drinking WaterWell ��o ft Dralhage Way�+ ft Property Line <</ i ft Other {t SKETCHI(Street name,dimensions of lot,exact locations of test holes&pore tests,locate wetlands In proximity to holes) ' `Z,L 0 D �t • k ZS.oo f1t ' DoGwooD • LAJk Parent material(geologic) �io�r�et R t l�U� 5 Depth to Bedrock Depth to Oroundwater. Standing Water in Hole: lA O n e Weeping from Pit Food Estimated Seasonal High Oroundwater 6 r Pg fe r +4q rr (W lr M T'd', rYvt DETERMINATION FOR SEASONAL'HIGH WATER TABLE Method Used: Vh 0•t.f (1 11!jt Depth Observed standing in obs.hole: In, Depth to still mottles: (3 'F In,• Depth to weeping from side of obs.hole: _In, Groundwater AdJustment ft. lndox Weil-0 Rending Dato: Index Well level..._„ Adj,.thetor,,,,,...,_„_ Adj.GroundwaterLovel,,,,_, PERCOLATION TEST Dute1 ji!bd Time (O:AM Observation. ; Hole# Tien at 4" V1 Depth of Pero f' Time at 6" V1 Start Pro-soak Time @ -d Time(9"•6") g End Pro-soak (� ' 3S Rate Min./Inch �P t Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Noeded(YIN). N Original: Public Health Division' Observation Hole Data To Be Completed on Back----- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conselivation Division at least one(1) week prior to beginning. Q:ISBPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Shcl Color Soil. Other Surface(In.) (USDA) (Munsell) Mottling (Stnucturo,Stoned;Boulders. a si ency.%'Oreyell 5gWy• Laa►n IQ ►2 2 r N owe f ri able Loawy 5g 07 4 (©KR 40 � f1r,101 We `s 14 -36 B+ ( ©aM cy Y 5q#W IIR ��6 Loose ?j�j— L3'3 tA0jV rh 5q#d to �f, Sr T " LOOSe DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Sall Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ---------------- s O.- 6 O. jot k�D ne. G ' 7 E L-mmy Sa b4 (0 't 1Z't A fir;A Logw. Sa+hd io �(R N/3 . Ft,igbIt' OA 135 C M '10 14hA 1'o S " Lao se DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(la.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soll Color Boll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders, Co i Flood Insurance Rate Map: Above 500 year flood boundary No— Yes . Within 500 year boundary No V11 Yes ' Within 100 year flood boundary No.v Yes pepth of Naturally Occurring Perylous Material Does at least four feet of naturally occurring pervious tntiterial exist in all areas observed throughout the area proposed for the soil absorption system? q e-S If not,what is the depth of naturally occurring pervious matorlal? Cer`tifiication I certify that on (date)I have pass ed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the requir tr alning,expertise nd experience described in�10 CMR 15.017. a `�N.OF Mgss9 Datt; 7ec 13, 2D 16 �� �y Signature — - �o DAVID �s o D. `-4 U COUGHANOWR cn Q:\9.EPTIOPERCPORM.DOC `rO /C E N SEA 0� EVALVP� r Town of Barnstable .. , gar nstable ��r ti Regulatory Services Department e;ca�j .ARNETABUL I b q Public Health Division m 200 Main Street, Hyannis MA 02601- 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2847 9015 . l October 4, 2016 MTGLO Investors LP 6011 Connection Dr. 51h Floor Irving, Texas 75039 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 17 Dogwood Lane, Cotuit,MA was inspected on 09/09/2016 by Shawn Mcelroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: 0 Stain lines showing system failure. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. C PER ORDER OF THE BOARD OF HEALTH C 4v� Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\I7 Dogwood Lane Cotuit.doc i Town ,of Barnstable anxtvsn►sce, . ,�� Regulatory. Services Department 1 -Public Health Division 200 Main Street, Hyannis MA'02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA. o Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation o Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town -Code §360-26 h) OTHER X o�in ) Ines &JU�e Repair deadline: Q�F WSEPTIMDEADLINES TO REPAIR FAI ED SYSTEMS.doc r Commonwealth of Massachusetts " � �"/� � d 72 77 -� ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' =' 17 Dogwood Ln +- -p l J' Property Address N Bank Owned (Contact David'Holt @ Today Real Estate T 800-966-2448) V Owner Owner's Name ) information is STY required for every Cotuit. MA 02635 9-9-16 s page. City/Town State Zip Code Date of Inspection .� 4W K?'I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see;completeness checklist at the end of the form. A. General Information 1. Inspector: r - Shawn Mcelroy Name of Inspector Upper Cape Septic Services " Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number I B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time-of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site f sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000).The system: Passes ❑ Conditionally Passes ®;Fails y N ❑ Needs Further Evalua ' by the Local Approving Authority s z 9-9-16 ,. Inspector's Signature Date The system inspector shall submit a co`p othis'ins ection 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form -� I;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,„ nt a i'' V ! � 17 Dogwood Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Cotuit MA 02635 9-9-16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: r ❑ 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. 4 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 • Commonwealth of Massachusetts - f Title 5 Official Inspection Form f' - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Dogwood Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966'-2448) Owner Owner's Name information is Cotuit MA 02635 9-9-16 required for every - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) - ❑ Pump Chamber pumps/alarms not operational. System will,pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break outf or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ `broken pipe(s) are replaced ❑ Y ❑ N, ❑ ND-(Explain below): ❑ ' 'obstruction is removed ❑ Y ❑ 'N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): r ❑ 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. .4* 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts :a= Title 5 Official Inspection Form i + 4'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J!a% 17 Dogwood Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)• Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) -• , 2: System will fail unless'the Board of Health(and Public INater'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 cir tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ' ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ' ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than %day flow ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official a Inspection Foam - �'�-'l Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments- 17 Dogwood Ln = - Property Address Bank Owned (Contact David Holt @ Today Real Estate 1=800-966-2448) Owner Owner's.Name information is required for every Cotuit MA 02635 9-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ,0 _ -j ❑ ® 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. t ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® t. Any portion ofa cesspool or,privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate,nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis 1 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ® ❑ 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 quesfion's in'Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply '❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑.. the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA) or a mapped Zone,II of a public water supply well If you have answered "yes"to an question in Section E the s stem is considered a significant threat Y Y Y� Y � , or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection . Form,, f i> Subsurface Sewage Disposal System Form Not for Voluntary Assessments 17 Dogwood Ln t J- Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Cotuit MA 02635 9-9-16 required for 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® - �.;❑ Was the facility or dwelling inspected for signs of sewage back up? ® -❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts 1° f Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments+' 4�-s 17 Dogwood Ln = k Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspectionA El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: _Design flow(based on 310 CMR 15.203): - Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Nori-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form 21 Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments E l �F; 17 Dogwood Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448), Owner Owner's Name information is required for every Cotuit MA 02635 M 9-9-16 page. City/Town State Zip Code Date of inspection D. System Information (cont.) .^: Last date of occupancy/use: Date Other(describe below): General Information ° Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:. gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool y ❑ Privy .. ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts (w., , Title 5 Official Inspection Form. N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 17 Dogwood Ln Property Address ` Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): x, Depth below grade: 12"feet Material of construction: El cast iron - . ® 40 PVC ❑ other.(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 311 . Depth below grade: feet Material of construction: t. ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)' ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Gip Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a' 17 Dogwood Ln Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" - Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): r Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 • A Commonwealth of Massachusetts Title 5 Official Inspection Fora l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 17 Dogwood Ln t J' Property Address Bank Owned (Contact David Holt @ Today Real:Estate 1-800-966-2448) Owner Owner's Name information is Cotuit - MA 02635 9-9-16 required for every page. City/Town 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 El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: ,., # A , 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts : z Title 5 Official Inspection Form- Al I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��:3!✓ 17 Dogwood Ln ' Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): : s Depth of liquid level above outlet invert 0 Comments note if box is level and distribution to outlets equal, an evidence of solids carryover, an ( N � Y rY � Y evidence of leakage into or out of box, etc.): D-box had stain lines above outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System SAS locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 6 Official Inspection Form;Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ • a=1 Title 5 Official Inspection Form f'i?`i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,_��!✓ 17 Dogwood Ln t J Property Address Bank Owned (Contact David,Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Type: ® leaching pits number:- 1-1000 gal ❑ 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.): Leach pit was empty at inspection with stain lines above inlet invert and into d-box. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments NEW _P_s 17 Dogwood Ln t J' Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. City/Town 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.): t.. y f Y. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - :a=1 Title 5 Official Inspection . Form f Subsurface Sewage Disposal System Form Not for Voluntary Assessments S �Sl 17 Dogwood Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Cotuit MA 02635 9-9-16 required for 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 ' irk, i { T • . } } A-3 - 49 13 33. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 mr Commonwealth of Massachusetts Title 5 Official; Inspection Fora lEl Subsurface Sewage Disposal System Form Not for Voluntary Assessments fw 4} 17 Dogwood Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 9-800-966-2448),,' Owner Owner's Name information is required for every Cotuit - MA 02635 9-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r Site Exam:. ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 20' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • a.•w Commonwealth of Massachusetts ,a=1 Title 5 Official Inspection Form i-211 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Dogwood Ln t Y Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Cotuit MA 02635 9-9-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 L0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRD-NM NTAL PROTECTION w RECEIVED iAP PARCEL , MAY 13 2004 W TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A - CERTIFICATION i Property Address: 17 DOGWOOD LANE COTUIT 02635 6-p C) -�l y •- ��4 Owner's Name: GAIL JOWETT Owner's Address: 17 DOGWOOD LANE COTUIT 02635 jUVVNE HOE? SNOEP� Date of Inspection: 4/22/04 NEP3 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: iSEPTIC INSPECTIONS Mailing Address: 'P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 i CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.M0 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally sses _ Needs Furt r valuation by the Local Approving Authority Fails Inspector's Signature: Date: 4/22/04 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect n. 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 SYSTEM PASSED TITLE V INSPECITON. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Title 5 Imnentinn Fnrm Am 5/,)nnn 1 Page 2 of 11 4� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECITON.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/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: n/a n/a 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: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a 1 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 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 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet.of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat 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. d _ Page's of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of breakout? X _ Were all system components,excluding the SAS, located on site'? X _ 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? X _ 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 X _ Existing information.For example,a plan at the Board of Health. X _ 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO 2 Water meter readings, if available(last 2 years usage(gpd)):ok C)3 J� i vC) Sump pump(yes or no): NO A Last date of occupancy: n/a L a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1987 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 BUILDING SEWER(locate on site plan) Depth below grade: 10" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:3" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 101' Sludge depth:0" Distance from top of sludge to bottom of outlet tee or baffle:34" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle:c --�q How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a i s 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Q Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6'H-10 leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAD I OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 3' IN IT.BOTTOM IS AT 71611 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Q f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. W Ck Qpp 0 03 �, as CA °J Cg i3 CC 1 Cb a 0 in Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 DOGWOOD LANE COTUIT 02635 Owner: GAIL JOWETT Date of Inspection: 4/22/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED FROM GROUNDWATER AT 12' NO WATER .() 1/ 0 U IN Commoriwevith of Mossachusetts John Grad Executive Office of Erivironmentai Affdrs D.E.P. Title V Septic Inspector Department of P.O. Box 2119 Teaticket,MA 02536Envlronmental Protection sox s��8 3, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A A CERTIFICATION 'BAR n Property Address: 17 Dogwood Lane Cotuit Address of Owner: , At 199? Date of Inspection:3121197 (If different) lHp'P4' << Name of Inspector:John Gracl Robert Marks:60 Duncan Lane Cente I e Company Name,Address and Telephone Number: 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 inspection. The inspection was performed based on Iny training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs urt r Evaluation B the Local Approving Authority performing at the time of the Inspection.My Inspection does Y PP 9 tY not Imply any warranty or quarantee of the longevity of the Falls septic system and any of its components useful life. Inspector's Signature: Date: 3130/97 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiitration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street e Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:.17 Dogwood Lane Cotult Owner: Robert Marks:60 Duncan Lane Centerville Date of Inspection:3121197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Dogwood Lane Cotult Owner: Robert Marks:60 Duncan Lane Centerville Date of Inspection:3121197 D] SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 17 Dogwood Lane Cotult Owner: Robert Marks:60 Duncan Lane Centerville Date of Inspection:3121197 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. nfaAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 Dogwood Lane Cotult Owner: Robert Marks:60 Duncan Lane Centerville Date of Inspection:3121197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: n1a Last date of occupancy: September 1996 COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: n1a Last date of occupancy: n1a OTHER:(Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last year. System pumped as part of inspection:"(yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1987 � Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Dogwood Lane Cotult Owner: Robert Marks:60 Duncan Lane Centerville Date of Inspection:3121197 SEPTIC TANK: X (locate on site plan) Depth below grade: 3' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 9'6-H 5'7"W 4'10- Sludge depth:4' Distance from top of sludge to bottom of outlet tee or baffle: 23' Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:5' Distance form bottom of scum to bottom of outlet tee or baffle: 0 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: nla Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) nla (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Dogwood Lane Cotult Owner: Robert Marks:50 Duncan Lane Centerville Date of Inspection:3121197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: nia gallons/day Alarm level: Na Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n1a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) Distribution box is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Dogwood Lane Cotult Owner: Robert Marks:60 Duncan Lane Centerville Date of Inspection:3121197 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Na Type: leaching pits,number: 1,000 gallon leach pit leaching chambers,number:nfa leaching galleries,number: nfa leaching trenches,number, length: nla leaching fields,number, dimensions:nfa overflow cesspool,number:nla Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The overflow was empty at the time of the inspection. CESSPOOLS:_ (locate on site plan) Number and configuration: nfa Depth-top of liquid to inlet invert: nfa Depth of solids layer: nfa Depth of scum layer: nfa Dimensions of cesspool: nfa Materials of construction: nfa Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) nla PRIVY:_ (locate on site plan) Materials of construction: nfa Dimensions: n1a Depth of solids: nia Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) nla (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Dogwood Lane Cotult Owner: Robert Marks:60 Duncan Lane Centerville Date of Inspection:3121197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' b c[ �� lO I GC Uo AAAC �5 M T ��L � �L �a a� DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11/15195) 9 No........ Flea..... ., ................ THE C•' MMONWEALTH OF MASSACHUSETTS , ��`.. B idR® OF HEALT - . .w'n Barnstable....To.......... OF...................................... Appliratilan for 11itipaiial Workfi Tomitrnrtinn '# Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Lot 6 , Dogwood Lane, Cotuit, Ma. ................__.................. • ................................................. ...---•-...........................-----••--•-----.....--------------.................---•......-- Location-Address or Lot No. ..Cedax...Acxe.s...Realf:y...Txuat........................... ......2-4...Gxeat...Pond...Dx..,...S......Yarmauth.,...Ma. Owner Address Ce dnr..�csQs...Realty---Trust........................... ......24---jGreat...Pond...Ar_.t...E......YaxmAutb..,...Ma. Installer Address Q Type of Building Size Lot22.,.7D_D...........Sq. feet aDwelling—No. of Bedrooms................3.........................Expansion Attic ( ) Garbage Grinder ( ) p� Other—Type of Building ............................ No. of persons.....................--.---- Showers ( ) — Cafeteria ( ) PaOther fixtures -------------------------------- ........................................................ W Design Flow...........5.5............................gallons per person per day. Total daily flow........ 00............................gallons. WSeptic Tank—Liquid capacityl.Q QO.gallons Length................ Width................ Diameter................ Depth............ x Disposal Trench—No. .................... Width.................... 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 ( ) � Percolation Test Results Performed by---CIO.rMaX1...GrIOZ-�MAn...F...B................ Date..... .UZU...._--___-__... Test Pit No. 1.......2......minutes per inch Depth of Test Pit.....]:.2.......... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...--................... --------•-------------------------------•-------------------------------.....---•---•--•......---••-......................................................... O Description of Soil....Q"-4•"---sand_.lga;ttj...4.".-24".-.subsoil--_24"-144" sand 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 TITLE 5 of the State Sanitary Code—The undersined further arees not to place the system in operation until a Certificate of Compliance has been iss d by the"ard_ heaW,-,/_..Signed•-•--- .•. --...._ -- ; ... .............. Application Approved By ......--- r a e --- Date Application Disapproved for the following reasons-----------------------------•---------------------------.........------------------------------........----•---- ---------------------•---------------•---------------------...------------••-----•-----•--.....---------•.......--.......---.........-------•---------.....------------------------......---•--------.... Date PermitNo......................................................... Issued---------..-:...------------.............:.......--.... Date No.._ c2_7J Fics...? S ........... THE C JMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................Town.............OF............Barnstable . .............•-----------•------........---... .Z ppliratiou for Diinpusaal Works Toustrur#inn Prruti# Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: Lot 6, Dogwood Lane, Cotuit, Ma. ................__._._.._.......... •-- .......- - --•---.....-------------•-•-----------•-------.....----------------........._......-•:............ Location-Address or Lot No. t' •--Cedax--A:or• w3--R,ee1 t�•-Trust.......................... .......24---Gr-eat...P-end.-D�.�.y...�Y Yar�th.j...Ma. Ow er Address ,Wa Cedar-..Acr.es Reta1. ► ua ------------------------- -......24•- Great---P."d--Dr.v-7_-S- Y&r oUthy.-.Ma Insta ler Address Type of Building Size Lot..2.,2-r7-Q.Q..........Sq. feet Dwelling—No. of Bedrooms.._........Y.._.j........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ..........._ No. of persons............................ Showers a YP g ----•----------- ...............P ( ) — Cafeteria ( ) dOther fixtures .------••--••......---•-••--••-•. ---.-------••-=•---••••--•-•••---•-•---•-----•••----•...............••-•-•-•....._..--•...--------- W Design Flow............5.5...........................gallons per person per day. 'Total daily flow........33 ----------------------------gallons. W Septic Tank—Liquid capacitylO.O]Dgallons Length................ Width................ Diameter................ D th................ x Disposal Trench—No..................... Width.................... 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 ( ) aPercolation Test Results Performed by....Norman---Grossman...P.X.............. Date.....9/lfi/RZ.............. ,.a Test Pit No. I........2.....minutes per inch Depth of Test Pit......12_!...... Depth to ground water........................ GZ4 Test Pit No. 2................Minutes per inch Depth of Test Pit.................... Depth to ground water........................ RI' ......••••••••-----•-•...............................•-•..........------....•-•-•--•--•-....._.............---.• ................................... O Description of Soil.....5?"_'-. ......sandy..lQam,_... _'!_�24"--- ubss il,---2-9_"..--14.4_"..ssantd............................ W V UW ---•••-•---•--- -------------------•----••----••------••••-•----•--••-•-•-•-----------...•-••-•••-•------••-•----•----•---------••-••-•-------•--••-••-----••-•-•......•---•--•--•••----•.......•---.--- Nature 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 IITi p 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. §jgVe .. ----------�pe ...... -- ApplicationApproved By.......................................................... ................................. ........................................ Date Application Disapproved for the following reasons--------------------------------------------------------•----------------------......--------•-------•-••------- ---•------•---••-•-•-•---•------------•---•••-•---•--••-•--•••----•-•-•-•..........-•---••.....-•------••-•-•••-••-•••....---•--•--•••--•-•-•••••-•-------•-•••-•••-•••••---•---•------•-------•••--•--- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............T.(M. ................OF...........Barns.tabs.e.......................................... (9rdifirat a of TompliFaurr THIS IS ZV CEMTIFY-,Xhat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..............•-• -- ...........Z`..................................................... ..•..•. ......................................................... ..,,.. / � t� nstalf at....................... .....-•----•-----•-••............ ......-•-•-••-----_.. ...--•--•---------------------•- has been installed in accordance with the provisions of TIT r of e State SanitaryCode as described in the a lication for Dis osal Works Construction Permit No....__. '�� � ! . _... PP P ----------------- dated.......................... --------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA TO DATE....................................................�1... - ...... Inspector. ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable 3� .. ........................OF..................................................................................... No..................... FEE........................ �i��rn�atl �ark� ��an��ra: ilan rruti� Permission is hereby granted.....C.eG 41_r...Acrez...Reality..`�'rust................................................................. to Construct (X) or Repair ( ) an Individual Sewage Disposal System at No.... tot...6.,...,At?WQQd...lt#T_e.r...Co uit.....ft............................................................................................... Street as shown on the application for Disposal Works Construction Per ........................................ -- -.... .......................................•. •• ---••----.....•--•..•••-- ..._....._.._ L' Board of Health - DATE....................... =:.....--•---•-----._...---..._...---•---- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - ...:.,-,--•.. #e...�n...: - -— - , ... ... . }..:< 1...:,. 4�.,K iC`� - — - art .-l'�.1_�.2 .r' ..Y ... r .. Y t .fig '>1''- .. .y^ "�. i.(•r.:.. C a. ., vS- M -:. / +01L„J.'►{..•N.1C�94��.�".ti`�i. . 7 .. '�, '. .]3„ ..'a... {,•�<. .. ,. .. .. "( .. ..tr.. '.l). ,.' „.+ �.i..+ . GFa,lE2-aL NOTEs �,, 5�,• - __-- ---_ '1 -_ALL E E-V Sbow►.3 AQF ML^.Q SEA►, LEVEL 1�'•S�D Cowl /��'� � �=;i SAT U►'"l P'LJ�.i.2lE ALL L &4ES A MIy,MUR� OF 1/,A../FCx.yT U14LES`_� OTNEE-&JME SPI(m 1EL7. -- -- AL-0- PsPC2p TO A W 0 ►" T� SYSTEM SF4At l_ DE CAST I1O►j 41c r� O t� n Cap ALL SEPTIC TAMK5) IPVST_V_kI5 TTiQ_1 8�rc, A"D �_ � LE^Cr.►�.J6, Prt r SHALL >tiE t7ES1C.�ED F-o2. N _� O O Q O �G' ® © 11 - �.0 v1++EEL J�CJ �- - - --- _ o-- >2 ENIpJE Au V�1Sv�rA3�c MATEZI L_ �E"E�.TL1 i � I��EeT- EL�EVA-r'Io.,1S of Prrs F<).0 /v►1�' �' N I ; __ �' L j O O C �J A Cn�u5 of i7 ,�O t�6 F_P til ITN Cvay-P-J? 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Mar-co sc^L-E Off �q UA L w�E-: T�+:i K S Q�C 1►.I Ft�CG.E D TNpo��!ou`r Ar,e c&4 A rio w AA7Zt = //,M17 /Anc 10 Wlrla ELF�CTeK. �L/ELDED W�� W�TFA / /� KIOTlra:ACIC- MAr.1NoL�� -ro P //j. %� ::e /� 2.4 -�/t ' rsM8E00ED S L (20>7'S ,J OB3e�Y.�T/oN5 QY: i tom''-�T s�Pr,c 7r►•x ^N+, tc..1_1416J6_ Pr3 .�.� . k AOAt0 a.- Ae,44Ty doTr0,-1- C400C. it, 4o0o >°sz. zBsT To AE IMWLT UP TO 1 Nc►{� , p1�+17t Tuev Fou.�S���,! ac Lcv., 1<��.►I S N ��r�>`�!s f,wblSK &4^04L r IIjt► C► GQA-►x p t�41S►F 6e� De Gv�� /!`1R1JSH GCI►DE• Q/Et 1W►4K y- GvE(L {��Cx /v LEA.CH 1G vpfT _� • , D e m m O • U 00 6AL • _ WF1E fTO,►It ,►J�'/y ,� �}p .yr ecwr«ccb �.�c. • pis-r tic O O O4.6 m .t • r(D O O o , n 1 .. ,Y 1 PTIG TAIJ O so _ 'f0 M LLVEL 4 a�TAIV LE 1 TVP1GA.L EWAGC 3XfS M P"FtLIE ✓ • 1�joT ToSc,*.CE LF_ACNINIO PPt ZX 0/ )J 7- ' �T LEG EA/p EXisT C'av7ocKAAA _.,_ PROPOSED D\,[/GLLI Q G LOCATION f jam' DES/GN C.e/7E!/_4 IV, PROP03E.D SEWAGE �015P0SAL SYSTEM 40 l _ .VvMBEe of �iEo.eor��ys 3_ 5OX"� E'x�Ir `..►mat El..fv ROBERT s , F. AO.E'OOM ' �v /i(A�• .�dl ELEI(/ RAYhfOND 4 L0T~ (� .Jt:" 'as'Lt J/� '�! •% 1;+:.� - ''' c�ALLGWS fse crL-leN AweP.4Y u �No.I9871�O,`+.` � � ' Lf•4!�/ilrc�r A?EA �eEQu/tEp ' i-= �� aesEt Trove PT. S� p � 1 /''_';r%�J ? ,/>,.,7; , MA SS . ZxAc h/i t/G AA44 �oV/DED 4 �i F N, - �.PPL.Ics.u^f' E►.1�11._(CLQ: �l 3 `1 100% E x PA K1 s 1 o N p KCIBERT �•v / ✓TjJ/ J1 7 r E.. r �� ! �/ = J • 1♦I'I itT , ' �7fs/ / RAY:MONDL SCALE: DAtE: �o��� r.r `r � / 1j 11► �1.�'CS%�'� - .AHn.[1:SR 4� ,5►sc; �•!.,v..,- .. ;,� _ y� �j`�r� I �� sJTi�ti Yt�7C/- •7 � NpV�~y. DRAWN eV CHKO BY ArrO BY: PLAN NO. _Q..