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Home My WebLink About0014 RUSHY MARSH ROAD - Health d <--,,A V 1\/1(ar-' Road Cotut -- -- — _-. - _ A= 019 - 017 C I mmom i i _ rt 009 000, TE _ T IEgg� 1�1 ' ■ No.. ... � Faso-�. .��.. ®� THE COMMONWEALTH OF MASSACHUSETT S BOARD OF HEALTH b� ........O.W h...................0 F...........a...h S i 0� Avp rtttuan for Dispasal Works Tonstrurtinn Vrrum Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at :ry 11 .........: ................... - --P�0. - :9 P`►. 5 ...��N ^W. .Location.Address........^ _ •----------- ... ' .•• Aonr.Lot No»........................».».».».._.. Owner Address .................... -. r�,L. . l.0 ---........................ ........ �. ---- .............. Installer Address j— Type of Building Size Lot. ..) ..-.Sq. feet Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ..........................•---.........................................................................•= . Design Flow............. ............ O gallons per person eyr�2�y. Total41y P w.................................�s..�lo s�ts�oser Septic Tank—Liquid capacity_�.____.....gallons Length.... Width:.............. Diameter................ Depth�-.� . . Disposal Trench—No..................... Width...._ Total Length......... Total leaching area....................sq. ft. Seepage Pit No...'52-Y!�.....•. Diameter.... •Depth below inlet..jg.. Total leaching area..545.- st ft-G1 D Z Other Distribution box ) Dosin tank ) Percolation Test Result ,� Performed b :.X ww'es �'� Date...1. 3 8G' y.......................... ....,.. �;.............. �.. .�........................ .a Test Pit No. 1.....---.-•---..minutes per inch Depth of Test Pit...... Depth to ground water......T�._he.... \_ G74 Test Pit No. 2................minutes per inch Depth.of Test Pit...._............_.. Depth to ground water..........�eo.... e d ® Description of Soil....�.'2-A.....�.V.�.SvbSo .....j,�-�'....� :..CAo��Se .............................................................•-•...------....................---•.............•••--•..........:.....................................---..................------••----... U 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 TITLE 5 of the State Sanitary d —The undersigned further agrees not to place the system in operation until a Certifi to of iance ee ed by t oar of 1 lth:�o Signed...... ............ .... .................. .. A�ff... . .. .................. ... . .. APP PP Y ._ j/ ate .... pplication Approved B ........ �........... ate Application Disapproved for the following reasons:...................:...--•--•----•-------.................-•---••--••--•----•-----..........................»» .................................................................. .........................................................................._•___.......................•..... .D�............. Permit No.......� .zs........-•--____......»» Issued................................................ »....» No.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !.a �..........--'--....OF... tJcchC 1'1S�ab1f� l ........................................ ........_.._........... dC� Applirtttion for Disposal Works Tonstrudion lirrmit Application is hereby made'for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at (Location-Address or Lot No. ---.. .._.._. ..... .............. .................................... �� : }gin Owner / ,Address ..........................».............. a ....• .........:. .......................•---•------•----•---.....- ..............................................._ ....-•--•--••--•------...... .............. Installer Address r1 Ir Type of Building l Size.Lot.*.......:.....`.Sq. feet Dwelling—No. of Bedrooms..... ................................Expansion.Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures .------•...............••-----...............-----....._......•---.......-- --•--------......-• ........ Design Flow...... .`��..........................gallons per person per day. Total daily flow........ 'c � lops WW p q p y. gallons Length...%?......... Width:_. Diameter................ Depth.... p...c. a Septic Tank—Liquid ca. acit ��?� �2 �"�:?:..- �-° �.- Disposal Trench—No..................... Width......... _........ Total Length � Total leaching area................_._.sq. ft. 3 Seepage Pit No..c)n ...... Diameter... . e Depth below inlet.. ..e :Total leaching area5sq-ft-G �. Z Other Distribution box ('X,) Dosing tank ( ) Percolation Test Results 2 Performed b _:.t�`��!!?o` ;.�` ''�,y.................. Date... ..'..� .............. a y...- ,..� Test Pit No. 1----------------minutes per inch Depth of Test Pit...... Depth to ground water Gk Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil...:C�.'2ky.. ?..� 'S '1bS�i ._ `:' ..........................vYti5ii � V .......................•-................................................................................ ' ..... _ W -------------------------------------------------•------------------------- -••-•••---------------------------•-- ........--------------•---------•------------•-....... ..... V� 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 AITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certifi to of o pliance s beeriis ued by the�board,of health: 1-6f Si Signed .. - / fD.....g �; .. te.: ra Application Approved B �. -.��- / a...,..- . PP PP Y Date Application Disapproved for the following reasons:.............:...............................................................•..........._......._..........__ ..........................................•--.....-•---^-•--._.."j.........---•---_.................................•--...•---•-•------•------•............__.._.........---....-Dat •----......_ e PermitNo...... ._.................... Issued........................................................ Date -r..ag�F+nX_ _.._ ,... —._.._�... .r+r.-t.-v-sr. ^.-�; a ".,a.. •�M w ...... ......_. �._.. ...r.-.._-...a»��_. x.. w s- w THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....F0.W. ................of .a k�?S - .. ........................ T ertif iratle of ffoutplitturr THIS IS TO CE TIFY, That the Individual Sewage Dis osaI System constructed or Repaired g P �' ( ) ( ) by....................................................# ;7";� .."...... .....�'1'.I.................................................................................-.. ..................... I`- Installer"` t has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code,as described in the %� 2 . application for Disposal Works Construction Permit N o.....� .... dated.....:_..` .... ..... ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A-GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT SFACTORY. DATE.. ....................... !! ...................... Inspector...... ."._._f`............_............................................ -w-o ti....,a.y i«._.x.,s a..u t•- .,..,,.....,. _...:'/ e m w�..Y a w.ti a s«.ti✓:..a a . ..u...,y<..........-»..w♦ �e. w u THE.COMMONWEALTH OF MASSACHUSETTS BOARD -OF HEALTH �..�'� " .."..'Y.. ............OF........ .. �...?.. ............ -• ..c G-. No., Fes........................ Disposal Forks Tonstrurtion Vrrmit Permissionis hereby granted..............................................'-----•--- ...................---........................................................ to Construct (/ ) or Repair ( ) a Individual Sewage Disposal System at No....Z:: ......�'.........../1 ...... � �G ...�-� - Street as shown on the application for Disposal Works Construction Permit N_o..�.�._G.`:S-cP--.. Dated....Z. Z --.........'..............................._ f� Board of Health t-c ` I `7�.i`.....��.. ............. ._ No. Fee 3T' I COMMONWEALTH OF MASSACHUSETTS Entered in comp.er: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for Disposal 6pstem Construrtion Permit Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) ❑Complete System D<Individual Components Location Address or Lot No. 14 RO I;aq x4(psij IZ) Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (D( 0l7 COT U fT A-GEADV &JAY t MA Installer's Name,Address,and Tel.No. S Off?—$ l Designer's N me,Address,and Tel.No. CA jV 6C c 8& �iSz�S Z, P �� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board i of d Date 9 A Application Approved by Date Application Disapproved y Date for the following reasons Permit No. XYL& Date Issued .. .- No. Fee X- 1 I 3 D NTE COMMONWEALTH OF MASSACHUSETTS Entered incompu ter: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pptiLation for Misposal opstem Construction permit Application for a Permit to Construct( ) Repair Q() Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. 14 RO S9\/ 9602.514 riZI) Owner's Name,Address,and Tel.No. Assessor's Map/Parcel p 1 At t i A &JAY i Dcic- MA Installer's Name,Address,and Tel.No. 5 p�,(�1T E g 17 Designer's,N me,Address,and Tel.No. 'CA jPLc.,tP6 EA1?b1 1e1156S C• PtL� Type n(�� of Build�g: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date , Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 1 ` 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 ig ed Ao Date 9 .Z i Application Approved by Date t Application Disapproved by Date for the following reasons " Permit No. Date Issued Th F COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance - THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed Repaired(X) Upgraded ( ) Abandoned b A� wI C� t ( ) Y C � b Ety'�'��K sEs «. at P USH K 141ARSf4 eD7U6 j- has been constructs i accord n e with the provisions of Title 5 and the for Disposal System Construction Permit No ed Installer (CAPE- Ar1_- (` 1 �1� L-4,C Designer 1\) A #bedrooms Approved design flow It gpd The issuance of this permit shall not-be constru 7d as a guarantee that the system Z1111 Eamon as designed d1' ' ? 'Date 1 lam/ Inspector /f /� , ;t -------------------------- - ------------------------------.-------------------------------------------- ------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS disposal 6pstem Construction 3pPrmit \ Permission is hereby granted to Construct( ) Repair(A) Upgrade,( ) Abandon( ) System located at 514Y 4��--�.pAb C/7 u 17 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 mu ff be plet d within three years of the date of this permit. Date Approved by 1z1lI,ep 07 14 07:08p p.1 ■ Commonwealth of Massachusetts ilills Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 14 Rushy Marsh Road Property Address Alison McCarthy_ Owner Owner's Name information is Couit MA 02635 9-5-14 required for every _ _ — page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please sea completeness checklist at the end of the form. Important:When A. General Information filling out forms I � 'tS on the computer. �o``��_Zµ OF►t rcf ••- use only the tab 1. Inspector: y key to move your cursor-do not JAMES m James D Sears = use the return Name of Inspector key. Capewide Enterprises,LLC �'•, o o - s 1 Company Name - ---- .�� `r....r�-• \�. 153 Commercial Street '%i,,,sr�INS�u Company Address --- -- — Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 _ Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority OpeZ�V" -- 9-5-14ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. d q1j tsrrs•3n 3 1.%, ionForm;suraunece sBwaos,Uis osel qe i or 17 p Syslem• a Sep 07 14 07:09p p.2 Commonwealth of Massachusetts, Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owners Name information is Cotuit MA 02635 9-5-14 required for every _ page. Cityrrown state 21p 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: ® 1 have not found any information which indicates that any of the failure criteria described; in 310 C M R 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Tank D Box and two pipe field. ,B) System Conditionally Passes: R ❑ One or more system components as described in the"Conditional Passe section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will Check the box for'yes", "no"or"not determined" (Y, N, ND)for the following statements..It"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 replacedf with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally soundi 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): a tSins•3H3 Title 5 Otlklal Inspection Form:Sutsurfece Sewage Dlsposel System-PaGe 2 of 17 Sep 0714 07:09p p,3 r Commonwealth of Massachusetts Title 5 Official Inspection Forme _ Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 9-5-14 page. City/rown State Zip Code Date of Inspection B. Certification (cont.) ;r ❑ Pump Chamber pumps/alarms not operational. System will pass with.Board of Health approval if pumpslalarms are repaired. - B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain below): s ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled orreplaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced '# ❑ Y, ❑ N . ❑ NO (Explain below): . ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): C)` Further Evaluation is Required by,the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public�health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR + 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•M3 Tdle 5 Official nspedbn Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm Not for.Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information is required for every COtUIt MA 02635 9-5-14` page. Citylrown State Zip Code Date of Inspection B. Certification (cost.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water = supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: •"This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 a ❑ ® 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 eso■pod is less than 6'below invert or available volume is less than '/2 day flow .4 FjP#/"G 151cs-3113 Tille 5 ORiclal Insperbon Form:SubsuBace Sewage Disposal System-Page 4 of 17 1 d60:L0 t,L Lo deS achusetts Commonwealth of Mass Title 5 Official 'inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Rushy Marsh Road Property Address " Alison McCarthy Owner Owner's Name requir required is Cotuit MA 02635 9-5-14 required for every page. Myrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation, ❑ Any portion of cesspool'or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any'portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached.to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the'above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with.a design flow of 10,000 gpd to 15,000 gpd. For large systems,,you must indicate either"yes"or"no"to each of the following, in addition to-the- questions iri 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 0 ❑ 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. t51ns•3113 Title 5 Official Inspection Fomr Subsurface Sewage Disposal System•Page 5 of 17 c•d do l,:L0 b l Lo deS Commonwealth of Massachusetts - Title 5 Official Inspection Form : Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name �. information is required for every Cotult MA 02635 9-5-14 page. Cityrrown 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 NIA) ® ❑ 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 i DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 61ns-3113 Title 5 Official Inspection Form:Submiace Sewage Disomal System-Page 6 or 17 j 1 g'd d0 6:Lo t,l LO deS Commonwealth of Massachusetts Title 5 Official :inspection Form - a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "f 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information is Cotuit MA 02635 9-5-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information r Description: The system is a 1000 Gal.Tank D Box Tank D Box and two pipe field. Number of current residents: 2 Does residence have a garbage grinder-?.,: ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes [Z No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2012-40,OGal's g ( y g (gP )�'' 2013-30,000GaI's Detail: Sump pump? a ❑ Yes ® No Last date of occupancy: Present • _ Date Commercialtindustrial Flow,Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? - ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? 0 Yes ❑ No Water meter readings,.if available: 15ins•3i93 Title 5 Official Inspedon Fonrr Subsurface Sewage Oisposal System•Page 7 of 17 L'd doI,:10t,l L0daS Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owners Name informrequired is Cotuit MA 02635 9-5-14 required for every _ page. CityfTown State Zip Code Date of Inspection D. System Information (cont.)', Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: - r Source of information: NA 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 ❑ Privy f. ❑ 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): 15ins•3113 Title 5 ofliaal Inspection Form:Subsurface Sewage Disoosal System-Page 8 of 17 g•d dll-1Oti6 L0deS Commonwealth of Massachusetts P Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 9-5-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: • 1984 -Permit # 84-327 New D.Box 9-14. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): _ Depth below grade: 21 feet Material of construction: ❑ cast iron ®40 PVC. ❑ other(explain): Distance From private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. ' Septic Tank(locate.on site plan): 1 _ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: . Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: t5ins•3113 , Title 5 Official inspection Fcrn:Subsurteoe Sewage Disposal System-Page 9 of 17 6•d" d I,I,:L0 t,I•Lo deS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information required for every COtuit MA 02635 9-5-14 page. cityrrown 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 29 011 Scum thickness 1. Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle- How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank at below grade wlout let cover at B". Intee,outlet baffle. No sign of leackage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑.metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: ' Date t5ins•3/13 Title 5 Of oal Inspeaion Form:Subsurface Sewage Disposal System•Page 10 of 17 �C d d 6 L:Zo b l Lo deg y Commonwealth of Massachusetts �l Title 5 Official Inspection. Form , oI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 9-5-14 page. Cityrrown 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 HoldingTank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): . *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspeclion Form Subsurface Sewage Disposa Systefr•Page 11 of 17 66'd dZI:L0t76'Lod8S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name Information is Cotuit MA 02635 9-5-14 required for every � -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet.invert 0 Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x21"-26" below grade w/two line's out D Box is new 9-14 wlcover at 6". Pump Chamber(locate on site plan): . Pumps in working order: ❑ Yes ❑ No* Alarms in working order. r ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): x 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-3113 Title 5 Official inspection Foam Subsurface Sewage Disposal System•Page 12 of 17 7 L'd dZ I,:Z0 I,Zo deS t Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 9-5-14 page. City/Town State Zip Code Date of Inspection D. System Information'(cont.) _ Type: ❑ leaching pits number. ❑ leaching chambers - number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1@ 32 ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note.condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r Leaching is a two pipe field. Ck D Box and camera out both lines. No sign of over loading or holding water. 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•3f13 Tide 5 official Inspedion Form:Subsurface Sewaao Disposal System-Page 13 or 17 £t d dZl•:LOtrLLodeS t Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 9-5-14 . 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.): Oins•3/13 Tte 5 Official Inspedion Fomx Subsurface Sewage Disposal System•Page 14 cf 17 til'd dol,:/0t?6 L0 deS Sep 07 14 07:13p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Rushy Marsh Road. Property Address Alison McCarthy Owner Owner's Name information is required for every Cotuit MA 02635 9-5-14 page. Cityllrown 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 10.0 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below , ❑ drawing attached separately dr 'r . 13 -1 19 151ns-:U7'1 i • - __ T7ts 5 OfRe;el Inapeet;«,Perm:o.a+nu.rueo o..-.rege olapoea orxem-reyn w ur 17 Sep 07 14 07:13p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 14 Rushy Marsh Road Property Address Alison McCarthy Owner Owner's Name - information is required for every CoUt MA 02635 9-5-14 page. Citylrown Stale Zip Code Dale of Inspection D. System Information (cont.) Site Exam: ❑. Check Slope ❑ Surface water " ❑ Check cellar ❑ Shallow wells a Estimated depth t high groundwater. 1 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 3 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: T.H. 9-30-83 11'+ no G.W..,Bottom of field around 5'below grade. Bottom of field at 6'above T.H. Depth. Before filing this Inspection Report, lease see Report Completeness Checklist on next page. L51ns•3l13 Title 5 Official his edian Form:Subsurface Sewage qga Disposal System•Page 16 0'1T t ' r Sep 07 14 07:14p p.17 Commonwealth of Massachusetts .fl �- Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Rush Marsh Road Property Address Alison McCarthy _ Owner owner's Name information is Cotuit MA 02635 9-5-14 required for every State Zip Code Date of Inspection page. CitylTown 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•3113 Title 6 Official Inspedon Form:Subsurface Sewage Disposal System Page 17 cf 17 r i' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Sean M. Jones cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 ten" City/Town State Zip Code (508)477-8877 S14522 Telephone Number License Number 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 sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority / 6/29/2011 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I V I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disp sal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning_in a manner which will protect public health, safety and the environment: J ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if.any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that.no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M •''v 14 Rushy Marsh . Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 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 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d yes 9 ( Y g (gpd)): Detail: 2009=26,000 total =71 gpd 2010=17,000 total=47 gpd 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every 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: 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 ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system installed 12-28-84 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ m'etal ❑ 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 gallons Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every 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 3.5' 211 Scum thickness 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 12" How were dimensions determined? opned covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet baffles intact and in good condition. Water level was at bottom of outlet invert, tank was not leaking and was structurally sound. Tank should be cleaned soon and again every 2 years as maintenance. F Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title5 Official Inspection Form p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 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.): r Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ _Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 " Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good working condition, water level was even with both outlets, no sign of past hydraulic overloading, no solids carryover. Cover is 2' below grade. Pump Chamber(locate on site plan):, Pumps in working order: ❑ Yes, ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 L_ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is COtult Ma 02635 6/29/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 40' ❑ 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.): Soil and stone surrounding s.a.s. was probed in various locations with no signs of past or present saturation. Vegetation was normal. 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 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. Cityrrown 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 P20iJ,T- OF H005e' � 13 E00 Z q•Z - 37 13- 2 A-3= 38 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,�M •° 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope. ❑ Surface water ❑ . Check cellar ❑ Shallow wells 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 14 Rushy Marsh Property Address Mary Margolius Owner Owner's Name information is required for Cotuit Ma 02635 6/29/2011 every page. Cityrrown 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 3 t q. a' h 1 }3 i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � TOWN OF BARNSTABLE LOCATION ��(V sa/`Y �f/�IA SZY SEWAGE# VILLAGE �� 0 /U i 7— ASSESSOR'S MAP&PARCEL NAME&PHONE NO. 0 SEPTIC TANK CAPACITY 00// C— A V 5��e C //0 4o, LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER J9 A t PERMIT DATE: CoIvfpttA-W—E DATE: 2 6/- 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 0A.r 57 �RIV ,o 3 �t 19L f \ COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form tl Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' Inspection results must be submitted on this form. Inspection forms may not be altered in any way:- A. General Information % 1. Property Information: MAP 019—PARC 017 14 RUSHY MARSH ROAD — COTUIT, MA 02635 ��% 0/7 Property Address MARGOLIUS, GARRY & MARY Owner's Name 14 RUSHY MARSH ROAD Owner's Address COTUIT MA 02635 City/Town State Zip Code SEPTEMBER 27, 2006 Date 1 4�4 2. Inspector: t C7D JAMES D. SEARS `X .. Name of Inspector s A & B CANCO ; Company Name _ �- C. 350 MAIN STREET ? Company Address C £33 WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2800 Telephone Number 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 sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: ® Passes ❑ Conditionally Passes / Fails ® ds Further Evaluation by the Local Approving Authority In ctor's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page I of 16 COMMONWEALTH OF MASSACHUSETTS m Title 5 Official Inspection Form d r Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Certification (cont.) 14 RUSHY MARSH ROAD Owner's Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Inspection Summary: Check A, B, C, D or E/always complete all of Section D A) System Passes: J ® 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: N/A ® One or more system components as described in the"Conditional Pass"section need to be replaced or Repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. ' Answer yes, no or not determined (Y, N, ND)in the ❑ for the following statements. If"not determined," please explain. ® The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of compliance indicating that the tank is less than 20 years old is available. ND Explain: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form � 9 y O,M $Jev`ev Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 14 RUSHY MARSH ROAD Owner's Address COTUIT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection B) System Conditionally Passes (cont.): 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: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ® broken pipe(s)are replaced ® obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: N/A ® 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 environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form 9 C Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 14 RUSHY MARSH ROAD Owner's Address COTU IT MA 02635 Cityrrown State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection C) Further evaluation is required by the Board of Health (cont.): N/A 2.System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: ® The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ® The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ® The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well** Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3.Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 r - COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments See Subsurface Sewage Disposal System Form B. Certification (cont.) 14 RUSHY MARSH ROAD Owner's Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection D) System Failure Criteria Applicable to All Systems: N/A 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 '/2 day flow - ® ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® ® Any portion of the SAS, cesspool or privy is below high ground surface water elevation. ® N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. ® N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] YES No ® The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd. 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection E)Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd: N/A For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ® the system is within 400 feet of a surface drinking water supply ® ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered,a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH,OF IVIASSACHUSETTS N w Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 14 RUSHY MARSH Property Address COTU IT MA 02635 City/Town State Zip Code MAGNOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ® Pumping information was provided by the owner, occupant, or Board of Health ® ® Were any of the system components pumped out in the previous two weeks? ® ® Has the system received normal flows in the previous two week period? ® ® Have large volumes of water been introduced to the system recently or as part of this inspection? N/A ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ® Was the facility or dwelling inspected for signs of sewage back up? ® ® Was the site inspected for signs of break out? ® ® Were all system components, including the SAS, located on site? ® ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ® Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 a COMMONWEALTH OF MASSACHUSETTS d Title 5 Official . Inspection Form Not for Voluntary Assessments 41 yB� Subsurface Sewage Disposal System Form D. System Information 14 RUSHY MARSH Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection 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 Number of current residents: 2 Does residence have a garbage grinder? ® Yes ® No Is laundry on a separate sewage system?[if yes separate inspection is required] ❑ Yes ® No Laundry system inspected? 0 Yes ® No Seasonal use? ® Yes No Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump? ® Yes E2 No Last date of occupancy: Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CMR 15.203): r Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.) Grease trap present? ® Yes ® No Industrial waste holding tank present? ® Yes ® No Non-sanitary waste discharged to the Title 5 system? ® Yes ® No Water meter readings if available: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection General Information Pumping Records: Source of Information: 2005 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 ® Privy ® Shared system (yes or no)(if yes, attach previous inspection records, if any) ® Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ® Tight tank. Attach a copy of the DEP approval. Other(describe): Approximate age of all components, date installed (if known)and source of information: AROUND 1984 Were sewage odors detected when arriving at the site? ® Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments 41 yev Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Building Sewer(locate on site plan): ✓ Depth below grade: 6" Material of construction: cast iron ® 40 PVC ® other(explain) Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ✓ Depth below grade: 8" feet Material of construction: ® concrete ® metal ® fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ® Yes ❑ No -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000-GAL PRE CAST Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum Thickness 1" Distance from top of scum to top of outlet tee or baffle 12". Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? PLAN, TAPE&PROB Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTIVIEBER 27, 2006 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): MAIN TANK AT WORKING LEVEL — OUTLET BAFFLE. NO SIGN OF OVER LOADING OR LEAKAGE. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: 1 ® concrete ❑ metal fiberglass ® polyethylene other(explain) Dimensions: Scum Thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ® fiberglass ® polyethylene ® other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Q, y8v Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Tight or Holding Tank (cont.) N/A Dimensions: Capacity p Y gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm Level: Alarm in working order: ® Yes ® No Date of last pumping: Date Comments(condition of alarm and float switches, etc.).- Attach a copy of current pumping contract(required). Is copy attached? ❑ Yes ® No Distribution Box (if present must be opened) (locate on site plan): ✓ Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX IS 16" X 21" —25" BELOW GRADE, ONE LINE IN —TWO LINES OUT. BOX IS CLEAN AND SOLID NO SIGN OF OVER LOADING OR SOLID CARRY OVER. Pump Chamber(locate on site plan): N/A Pumps in working order: ® Yes F-1 No Alarms in working order: ❑ Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments 41 y0� Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): ✓ If SAS not located, explain why: Type: leaching pits number: ® leaching chambers number: ® leaching galleries number: leaching trenches number, length.- leaching fields number, dimensions: 16' LONG ® overflow cesspool number: El 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.): LEACHING IS TWO (2) PIPE FIELD 16' LONG. INSPECTED WITH PROB & CAMERA. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form d� Not for Voluntary Assessments io,1 Vey Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)-. Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 r COMMONWEALTH OF MASSACHUSETTS a _ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTU IT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.. Locate where public water supply enters the building. I Fide; :I':iccd!nsprcuor.r,,rm:suosurtho:4e :me:.i>r:••.d S..tcm COMMONWEALTH OF MASSACHUSETTS 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 14 RUSHY MARSH ROAD Property Address COTUIT MA 02635 City/Town State Zip Code MARGOLIUS, GARRY & MARY Owner's Name SEPTEMBER 27, 2006 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to NO ground water: 8' Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record if checked, date of design plan reviewed: Date 0 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: 0 Checked with local excavators, installers—(attach documentation) 0 Accessed USGS database—explain.- You must describe how you established the high ground water elevation: TEST HOLE AT 8' NO WATER, TEST HOLE 5 BELOW BOTTOM OF LEACHING. 3' I IV ule;ntlicial I ;pecu+n P•x Su4sur.ace::�,. ooxal.5 v .:m • 'No.....- . ... ...... Jr F3cz THE COMMONWEALTH OF MASSACHUSETTS B6ARD OF HEAL'T-H, ...........................................OF..... ..... 7 . ................................................................................. Appliration for Disposal Yorks Tonstrurtion rrrmit Application is hereby made for a Permit to Constru'c't (�r I Repair an Individual Sewage Disposal System at: A ............2............... 1�e�o ti rr r is.s....... 511eAer —Address ......................... .................... .................................. .................................................................................................. pq Installer Address U Type of Buildi Size Lot`........................ Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................ Showers ) — Cafeteria Othev�vs ........... 1 3.. .................................. ---------------------*--------------*-----------------------------------------**...... .................. Design Flow............................................gallons per person per Total flow galIgns. Z�i �4WE� 1 _iqui ci ........ -gallow,Septic Tank—L*"I * 'd t Length!��........... Wid Diameter.__..............D Disposal Trench—No.....................Width-___................ Total Length.................... Total,leaching areat�. -.sq. ft. Seepage Pit No..................... iameter.................... Depth below inlet......._............ Total leaching area..................sq. ft. Other Distribution box Dosin nk Z �WV7Z� �F 114,LDate...._-..___._-.._.... �//zv/�7v Percolation Test Resul!�, Performed by................................ Date.. ........ -----------7------------------- ------ Test Pit No. I minutes per inch Depth of Test Pit........ ------- Depth to ground water.... gr PLf Test Pit No. 2.Z:�: ....... ...............minutes per inch Depth of Test Pit............. Depth to ground water---/.................. .............. ......................... --------------------- ------------.......... ......*........ 0 Description of Soil.... -- -- ----- Sii ...................................................................................... ----- - -----------------------------_-.1-----------------"---------- ------------------------------- -------------------I---------------I--------Z ------------ I ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with an tar T" ersigned further agrees not to place the system in S y the provisions of TITLE 5 of the State Sanitary The uni,( operation until a Certificate of Compliance has e t!g jj ...................................................... ............ ate ApplicationApproved ...................... ...................................................................... .................. ate Application Disappr� for the following reasons:.............................................................................................................. .......................................................................................................................................................................................................... Date PermitNo......................................................... Issued...................................................... Date THE'COMMONWEALTH OF MASSACHUSETTS .BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Tompliaurr IS TO U dFY, That thend;vid al Sewage Disposal Sezmynstructed(�or Repaired ----------------- ....................................................................... --- -------- --- --------- -------------Installer at.... ..... .................................. ..................................................................................................................................... has been installed in accordance with the provisions o ,j_7 he State Sanitary Code as described in the application for Disposal Works Construction Permit 110........................................ dated.-_.._____._______.............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE0 AS A GUARANTEE THAT THE SYSTEM WI L FUNCTIONS D� ....... . .......... ................................ Inspector....--.— 1. .. ..............fleit;flij....Li.-n-s.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... ........... FEE... ................... Disposal Works Totto ion Vitrutit Permission is hereby granted........................ ......bz.. . ......................................................................... to Construct orb Repair an Individual $ewage Disposal System atNo...........................4a;X.r.....t�........ .......... .............................................................................................. Street as shown on the application for Disposal Works Construction Permit No..................... Dated........____.............._.........._.... ........../# .......................................................................... Board of Health DATE................................................................................. FORM 1255 A. M. SULKIN, INC., BOSTON Q No f�.............. r ............................. THE,COMMONWEALTH OF MASSACHUSETTS 39, ' YOAR®� ®F HEAL�H�' 40//Yl •--..... .....OF......�� r� 14 STL�-................. Appliration for UiipusFal Works Tomitrurtion Frrutit Application is hereby made for a Permit to Construct Repair ( an IyiZl idual Sewage Disposal System at: I ......... ............&e ....... .r � ,kS a' Ad e r f ...................f.� ... ��..-�-- ------------------ Owner Addres s �r- ............................................................ Installer Address U Type of Building Size Lo __Sq. feet �-, Dwelling No. of Bedrooms........ ............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow...........lltl....................gallons per person per day. Total daily flow------_3Z .....................gallons. WSeptic Tank V Liquid capacity/l�:? f.!.-'_gallons Length .. _.. Width.-�®_._ Diameter................ Depth—_' .__. x Disposal Trench—Ncs :'� 1�� ':�7Vidth lZ _.._...... Total Length---Z-42....... Total.leaching area.3.42- ----- ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box (t/)' Dosing ( . 5 � _2 W Percolation Test Results Performed b �_ 11�,!!G................................ Date..._ - .. f/ 7 Test Pit No. 1.._...ZZr-......minutes per inch Depth of Test Pit......., ........ Depth to ground water_-�-- ---_-- Ps Test Pit No. 2..._Z—__..minutes per inch Depth of Test Pit...fQ.__.... Depth to ground water...-�.d._._... •---•--------- -----------------------•-••••••--- -----------....---•-- 0 Description of Soil......................... _--_. .... �Sv x .----------------• ..-'�G? = �1�1�=-- —�' ----------•------------------------------------V 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 TITIZj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' by the boar of health. igned•-•--• . -•-• -• -•------=---------- Application Approved By• ---•-_... = _... ...... • --------------••--. Date Application,Disapprove the following reasons----------------------------•--------------------------•---------------- ...................................... --.......-••----•--...•••-•--••••-----••-•-----•...-•-•-••••---•-•-•••-----•--•••-----•-•-...•-----.......--••--•----._...-•--••....---••-•--•---•••-----••••--••--••-•-•-•----•-•---•-••---••-•---••---- Date. Permit No...... . s A.7.......................... Issued.... 1� - PERMIT NO. < DATE / OWNER ADDRESS r/asS INSTALLER �,e JOB LOCATION INSPECTION DATE I� \ II® NEW CONSTRUCTION 31 i 39 . wv BOG c i, SECTION SEWAGE f 1 I i 44 a _. 1=rzola'rt 30 ir: 10'-SEPTIC TANK - "D" OX - LEACH— 00 45 �TOP OF FDN tt 7�- ' (MSL)* _—„2..OFIlaTO4i" t V GNASHED STONE {v\ I �! A t \ IN- y lk- OUT• IN• OUT• IN ccvEEf ./ q AIT 4 1�F TANK �C' 1 2,�0 ELEV. ELEV. ELEV. ELEV. Af.53 Ae.3 ELEV. ELEV. - OF 3/4"-142r. WASHED STONE YAK- 9 [J} TEST HOLE LOG EXI �1�' i� !rou TEST BY ' t2 WITNESS I ' TEST DATE � I� I F/�O DESIGN BEDROOM HOUSE., /— T.H. 1 1 T.H. 2 M �� % ' S0 - -. ELEV. A41 ELEV. NO t7 DISPOSER DISPOSER PERC RATE MIN/IN. FLOW RATE llOK31,5(GAL./DAY) ,a SEPTIC TANK.tlq�j�Z REQ'D'SEPTIC TANK SIZE IUoO LEACH FACILITY - _ J . ,LI/AVSIDE WALL 0'� - r4esp s i3O G/D. 1 j / , . �� r M,@ BOTTOM 2 _ •�l I,Op G/D. ��'' 32ZT) USE: LEACHING -WATER ENCOUNTERED ENCOUNTERED NOTES (UNLESS OTHERWISE NOTED) 49 2.DATUM(MSU* TAKEN FROM w��u Ua —QUADRANGLE MAP A� 2.MUNICIPAL WATER L� oVA1LABLE �� l 17''ICJ 3.PIPE PITCH:14"PER FOOT 1'' t; 4.DESIGN.LOADING`FOR ALL PREoCAST UNITS:AASHO- H I 0 -440 S.MIN.GROUND COVER OVERALL SEWAGE FACILITIES:(2)FT. �s �OJJALA 6:PI;PE 4✓INTS SHALL BE MADE WATERTIGHT l 7-CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. - No. O 80y 2 H k, �GJ STATE ENVIRONMENTAL CODE TITLES tH Of 8. T�a.�. a�.s.v Pot �r�� ► ,a+>LIC o. ,�.r ��o � „a O .qEC gyp` Nq�� LOCUS: L T 4 OL:D PC?�. IT Rt:7 W o/ Cy r-�o c-: �E uD.'-ate '�iro� +`f t_.uG ��.�,+. ►G� G •�E � p'. � ARNE - .REG.P — NGIN H. .. R y _ -N L'E EE H I i o,lA�. p8r 329 Pc-, aa�a PREPA. E Fit//! O/. a►n :ca�� engin g �f� G) R D.FOR• CIVIL'ENGINEERS- AZ Y S 44 BOARD OF HEALTH . LANDSURVE OR � - REG.LAND SURVEYOR- tt � t/1C A - CONTOURS (EXISTING)............. APPROVED tJ-,TAf3L� MA ties e+�ss<, SC LF p � (PROPOSED)-O-O-O'O- . DATE t f. DATE #oE� i mm .1 4. REVISIONS: TEST PIT DA TA DATE TESTING:_ 9f3; ?; PERC. TEST DATA : SEPTI C TANK DETAIL : sIzE- GAL. DIST. BOX DETAIL : LEACHING FACILITY DETAIL• DATE TEST BY `- '." ;��`° 4 ''✓' DATE OF TESTING "f. TANK TO CONFORM TO TITLE 5 REOUIREMENTS. TO CONFORM TO T/TLE 5 REOUIREMENTS T. P. W/TNESSED BY _ .TEST BY., y�,•�,ti-�.�.;vg; /,4.'� NO. OF OUTLETS J `�- WI TNESSED BY a . ati �,. n1i,. .��. .ai. .�. - - -- - -- - - - �12„ r3a� �r �/� 1 �1'//c- JINP =�'T��?��, �y REMOVEABLE COVER .4+E.c.K MANHOL BROUGHT TO FINISH GRADE. ..' 2PEASTOACi3AYOUTLET PIPES a 3 CLEAR 3 q$ REOU/RED6 M/N. 2M/N•DEPTH of TEST ,� - -- INLET ; RATE --1'21iNCL/ - - --- /O M/N. II�� ; D/ST. << ?y w�srtEU s-stw ---- -- - --- IN TEE OUTLET TEE 4"C/ _ GAL BOX INLET AND OUTLET 4' 0" MINIMUM OUTLET TEE DEPTH �2„ 6„ SEPTIC TAAIK FEES TO BE CAST L IOUID DEPTH /4 AF LIOUID DEPTH OF 4 o L --7` - - DEPTH OF TEST IRON, SCHED. 40 24" 6' . • >. b. a . CONCRETE /O +c >- r 7 C P V C. OR CAST/N 29 „ T' ',° -' CON T/ON RATE' PLACE CONCRETE CONCRETE „ „ M/N. - 34" " B� BOTTOM ON LEVEL STABLEBASE (WAVER GH CO �N • .. .o ZoNF O. TEE PROVIDED WHERE SLOPE FOUNDATION �- ` % E.L ':Tr*41v " L ET PIPE EXCEED S OB % OR TO TANK BEABLE TO WITHSTAN D IN A PUMPED SYSTEM. BO T TOM OF TANK ON LEVEL STABLE BASE 20 M/N. H-lO LOADING UNLESS UNDER �- -- -- - - -- - - - - - - -- - - -- ----- PAVEMENT OR IN OR/VE. H-20 4 LOAD/NG UNDER PAVEMENT OR DRIVE. 2,- �ecrrcy y A - i� NOTES : PLAN VIEW : INVERT ELEVATIONS* I. THIS PLAN/S FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE DISPOSAL FAC/L/T Y ONL Y. SCALE / 3Q ' INV. AT BUILDING /0 , ~- 2. ALL CONSTRUCT/ON METHODS AND MATERIALS SHALL CONFORM TO _ _INV. AT SEPTIC TANK(IN) MASS. D.E.0.E. T/TLE 5 AND THE L h 4':►�- 7:� g-, E BOARD OF HEALTH REGULATIONS. __ __—/NV. AT,SEPT/C TANK(GY/T'J _ . _ •� SAL Y!v� WILL Mo 9016 /NV. AT DIST. BOY11NJ �� s� � ' s�c-r ate, r�'Hrt icn; c.a��-c+;�ts S rr�.��ra ��.►��N r.:v,�n �N s �- ,pry� /NV. AT D/ST. BovouT) _ c_i / INV A t`,�C�• +!c , �9Bv ; �2tsJi��3J ��2 ; `�a3 � -ri/F�Es3} �}w1G 4�z4�S•4 /6Y� l�N.+KriG:r.? t •,., NC. r4AJL) A107- 'r", COC//�/L� a'C./" 4'` / w«` 12 WORCESTER, MASS., NV 47 ai-iQ r rMi. I ,� HALIFAX, MASS. NORWELL, MASS. -- --'---- BEDFORD, MASS. LEXINGTON, MASS. TT Rr�l ^, +•i ;,; �, __ HYANNIS, MASS. MANSFIELD, MASS. CRANSTON, R.I. DERRY, N.H. 'cC3o- DESIGN DATA DESIGN FLOW E3 !E; 117w: 44 I /g� / �� (��•�i�`�� '� J :�_��r�t x 11� ..iF'L ` -::�'�r_�_ �•? : r Rr, - - - - - -- ,4. 1 i REQUIRED SEPTIC TANK: 495' GAL. 'SEPTIC TANK PROVIDED = c '%- GAL. CAPE COD SURVEY REQUIRED SIZE LEACHING FACILITY: CONSULTANTS _ -- -- --- -: 76 ENTERPRISE ROAD HYAN'NIS en ��,Q{= , MASS. 02601 -- -- - - - ----- \ -- - - - - --- ---- - (617) 775-7815 ,. -- - - - - DIVISION OF BOSTON SURVEY CONSULTANTS INC. I SIZE Of LEACHING FACIL/TYPROV/DED: ENGINEERING SURVEYING PLANNING TYPE OF-SYSTEM ,�t,�� M,w�.• �, .� TITLE: _:x !qC ( ;s�rJ .ate ,ecCL^ -- f3t3 r/'�?'Aa. € -. _ � SEWAGE DISPOSAL SYSTEM F I Q 69 r->/S r_ �o �� ,� ' � � � �� --- ----- - ---- - _-_--- -- - - - --- DESIGN r / c, —----- ------ f' LOCUS PLANS 01 ) 4ttiv1 ; �M.H }= �` �wQ °. FO R C;,•_v `- .'_ «ri+ SCALE: AS SHOWN METERS FEET 0 DATE: s T,,�;..,-r 1 i a,i COMP./DESIGN: SAW s`= CHECK: /7) /4 DA TV/Y/ ' "✓ . V. Z) DRAWN: %�►v FIELD: k't 4,4 �- r��.4N /rJ Co r c1/ T FILE NO: DWG. NO: -7014 1. JOB NO: a , ' l .. .•��/'ff-fI ; Q,l..?��&�4 d; t�'rx 't .v�`E, ANC, SHEET: I OF: I