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0091 WATERFORD DRIVE - Health
(� 91 Waterford Drive Cotuit A= 056-002-010 f I r t 05-&,00 a- a l 0 Commonwealth of Massachusetts �v ,F Title 5 Official Inspection Form il° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r L � < 91 Waterford Dr Property Address F ti Owner Gugliotta information is Owner's Nam required for Cotuit Ma 9-29-2020 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: When filling out A. Inspector Information Sf Iliq0 � forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address r� Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-29-2020 Insp or'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection do s not address how the system will perform in the future under the same or different conditi s of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ! Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L� 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection this system met all passing requirements.This report can not predict the future performance under the same or increased usage. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 1 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ~^� � 91 Waterford Dr v Property Address Owner Gugliotta information is Owners Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �v iig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 � 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotult Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool Is less than 6 below Invert or available volume Is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is)within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts m l-F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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 backup? ® ❑ Was the site inspected for signs of break out? J ❑ ® 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. 0 ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form '. I' Subsurface Sewage Disposal System Form Not for Voluntary Assessments f; 6 � 91 Waterford Dr v Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 Description: This system consists of a existing 1000 gallon septic tank and a Distribution box and s.a.s that was installed in March of 2016 Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail I tried to get water readings but the water dept never sent them to me. This system IS NOT designed for use with a garbage disposal. Sump pump? ❑ Yes ❑ No Last date of occupancy: Date l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 p Y ry v� 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: tank was pre existing s.a.s and d-box were installed in March of 2016 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was functioning poperly at time of inspection. If the tank has not been pumped since the new s.a.s was installed in 2016 1 recommend pumping at time of transfer and every 2-3 yrs for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �b Title 5 official Inspection Form 41� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for COtuit Ma 9-29-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� v 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): Box was functioning properly at time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments u 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11: Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments >l� 91 Waterford Dr Property Address owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S.A.S was functioning properly at time of inspection with no signs of failure. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r• Commonwealth of Massachusetts �R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �m /,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 6 / 91 Waterford Dr u Property Address Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^ � 91 Waterford Dr u Property Address Owner Gugliotta information is Owner's Name required for COtult Ma 9-29-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record Ili If checked, date of design plan reviewed: Sept of 2020Date ❑ 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: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �u lP Title 5 Official Inspection Form ° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr Property Address a Owner Gugliotta information is Owner's Name required for Cotuit Ma 9-29-2020 every page. CityTrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 'Assessing As-Built Cards Page 1 of 2 TOWN OTF�BARNSI'ABLE n LOCATION Q� [Afereri{`�_V_f —SEWAGEN�C7lG" VILI.AGEILJ6��,Jl_ASSESSOR'S MAP.fe PARCF,IaG_(? a Ql INSTALLER'SNAME&PHONE NO.t�.0 _:" It pLk5 _LfJf'. _- SEPTICTANK CAPACITY& LQ JOA LEACHNG FACILITY:(type) ��}f�prMItIP C( (size)_Alm NO.OF BEDROOMS 3 OWNER \I — PERMITDATE: a & _COMPLIANCEDATF.:�'��'ICa Separation Distance Between the: fjotje a'r pF-11 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility —_------- Fcet Private Water Supply Wall and Leaching Facility(If any wells exist on site or within 100 fat of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands a within 300 feet of leaching facility) Peet FURNISHED BY 'tl ww•l'Tv?v Us LV _�� ZAdc W, SUS i� I -NS�6 �i S' opPf https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 9/30/2020 Assessing As-Built Cards Page 2 of 2 https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 9/30/2020 No. a o l Ga 6t�1,� Fee COD -- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: `/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(1') Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No.q t (Ak,+e& tT Owner's Name,Address,and Tel.No. / C Assessor's Map/Parcel p C9�c��S trn" C �,ovely �OGu'�n /�h l{i5blt Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ^ kJc7J0CcS A ?6fCha7nJ TNG l NC'e( LNs W r Type of Building: Dwelling No.of Bedrooms Lot Size Lj!a;u90j sq.ft. Garbage Grinder( ) Other Type of Building r,es_►c�eN�IC.A No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ?,30 gpd Design flow provided 3 H$J gpd Plan Date [ -'�7_1 Co Number of sheets Revision Date Title Size of Septic Tank N1k1,%tm Type of S.A.S. a -SOU CXCA64 C_\A&M64S (A) 1{� sfn(0e— Description of Soil Nature of Repairs(or�Alterations(Answer when applicable) t >JSC✓V1C� �l S-OD aA0l� VlGMk6ers (�9 ��'� S+-c) 1)e CtS �l/10W N L3N 9\Wy Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. `� Signed ® �.L!� �--� Date Application Approved by j/N/ (V�,�tL,,� Date 4_3 r(Ce Application Disapproved by Date for the following reasons Permit No. (0 Date Issued Z —3 — L— -_------------- -- --------------------- ---�_-- ------ - r. r ` No. Clip I ()A(/> f i Entered in computer:Fee (Do. e t ' THE COMMONWEALTH OF II ASSACHUSETTS '•Ies PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ipliration for Disposal *pstrm Construrtion Permit Application for a Permit to Construct( ) Repair('") Upgrade( ) Abandon( ) ❑Complete System E�Individual Components Location Address or Lot No.r(( ( �Ef7( 1�✓ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel U S — ���� �CC�SS IMG IJ ove��) , 104;.��rc �C►� (�Sbl1 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �1 & -0c7JS)G S A 1�>(c x),-j I'NC Type of Building: Dwelling No.,ofBedrooms Lot Size � f3;!Jqj sq.ft. Garbage Grinder( ) Other Type of Building eeS►clp,,3 h L,\ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3-3() gpd Design flow provided 3 H 8,7 gpd Plan Date l -dt 7^ l G Number of sheets a Revision Date Title '' Size of Septic Tank (0,IIS+kNC Type of S.A.S. a -5OU GCc.II6ri CV1rnn6(S i.l u 1 s-fo0I_ Description of Soil ` Nature of Repairs or Alterations(Answer when applicable) 1 rJ S t[., 1 G N P W C) - 130y, C') --. 5500 �\�r� �Aam0&(s \ \ N ' �+rwe c,- �4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by —L Date .— (p Application Disapp'royed by Date for the following reasons Permit No.—�;o I•( —1) /� Date Issued r-3 ----------------------------/------- -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS j Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( V)- Upgraded( ) Abandoned( )by*_ \ Ur o ry 1 ti c- at G l' { AA(,jAC),-4s ft'\klt, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. E) oa�dated 2 3-l4 Installer Do\o lc.,S A�i(c)')n1 c e C Designer r N J%A3&e{t N3 C3 / �[g #bedrooms "3 Approved design flow '��(") gpd The issuance of his pe it shall not be construed as a guarantee that the system wi 1 fun t'o as deli tied. Date ' Inspector ----------1-------------- ------------------------------------------------------------------------------------------------------------- No. �o i� b A10 Fee (7d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Vsposai 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( 7 Upgrade( ) Abandon( ) System located at CA I 1,t7CAAV.Y IvS and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. ! Date 7j Ito Approved by Y V v VVL' - C Tawn of B rnst Able Regulatory Services Thomas F. Geller,Director ` Public H�e IIivio . ThamasMcKean,Director 200 Main Street, „Hyaanis, MA 02001 Office: 508-9624644 Fax: 5fl8-7904304 Date: Z Sewage Permit#.(%,0;�(,. Assessor's Map/Parcel Iustalller.&Rmimr-C.D*Acation Form - Designer: >Crya �e�-t.rT T'iGEn+ee 1�E . Desi W o r Lc r l nc Installer: T)A •V g- _ Address: 12 W. Cra S she tcI 1 Address: to ;._ [,may, On 2 9,A`6 Q6Ui was issued a pernut to install a (date) (installer) septic system at ' M �M-Ii.t based:on a design dlawn.by a ess dated I .7--77 l (designer) --- I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the dtstri}�tition box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the.septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system..-) but in accordance with State & Local Regulations. Plan.revision or certified as-built by designer to follow. Stripout (if required) w ....ed and the soils were found satisfactory. PFrE.t r er's Signature) WEN7EE . CIVILWARN J v, .PZGM, (Desgper's Signature) (Affix Design ) PLEB AETUPIN TO BARNTAHIsE':PU :t.r.SEAL. : I3TVISiON. RT ATL OF CO a:IANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- . BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANKIMOU. gAoffice formsldesignercerdfication form.doc „ s Barnstable t� * Town of BarnstableAFAm d Regulatory Services Department e`eaC j HARNSTABLF- MASS g I Public Health Division m iOrFn ram'' 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7014 1200 0001 0358 7603 9/9/2015 ` Herbert Grossimon 91 Waterfield Drive Cotuit, MA 02635 t ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 91 Waterford Drive, Cotuit, MA was last inspected on • 8/19/2015, by Michael DiBouno, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed” under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet (per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. • The Distribution—box needs to be replaced. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B ARD OF HEALTH • � h c ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\91 Waterford Dr Cot Sept2015.doc Town of Barnstable • BARN&rAst.R, A b 9 ,.� Regulatory Services Department rED MA't� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). V TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation 1 of a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code 360-9.1) OTHER Repair deadline: up a Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc j } 9/8/2015 Parcel Detail Q. Logged In As: Tuesday, September 8 2015 Parcel Detail Parcel Lookup Parcel Info Parcel ID 056-002-010 I Developer Lot LOT Location 91 WATERFORD DRIVE I Pri Frontage .150 _ I Sec Road EAGLE POND ROAD I sec Frontage 135 I village COTUIT I Fire District COTUIT T I Town sewer exists at this address No Y I Road Index 2187, Asbuilt Septic Scan: - { Interactive Map f 056002010 1 ' Owner Info owner GROSSIMON, HERBERJ Owner co streetl 91 WATERFORD DRIVE street2 _ I city COTUIT state MA I zip 02635 Country y I Land Info Acres 1.11 use Single Fam~ MDL-01 I zoning ,RF I Nghbd 0106 I Topography Below Street I Road ,Paved utilities Public Water,Gas,Septic I Location Construction Info Building 1 of 1 Year t1989 Roof rGable/Hi Ext al Built ,Wood Shingle h Struct � p Wall g Living 2399 Roof Asph/F GIs/Cmp AC Central J Area Cover Type Be Style Cape Cod wall Drywall�J Rooms t3 Bedrooms Model Residential J Floor Hardwood I Rooms 2 Full-1 Half In Grade Average Plus "eat,Hot Water T Total 7 Rooms Type Rooms Rooms r Stories ;1 Heat Found-1/2 Stories Gas Poured Conc. Fuel �_ ation Gross 6294 J Area Permit History Issue Date Purpose Permit# Amount Insp Date Comments 10/1/1991 Addition B34642 $10,000 1/15/1992 12:00:00 AM CO ENC DK 6/l/1989 Dwelling B33003 $0 1/15/1990 12:00:00 AM CO 11/2 S http:/Iissq l2/intranet/propdata/ParcelDetail.aspx?[D=3580 1/3 c «_p Commonwealth ofWassa �0 chusetts R- ; =�6 Title. 5.,Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - - - 91 Waterford Dr - - -- - _. _. Property Address = . Herb Grossi,rrion rj Owner h _. .. Owner's Name/ information is required for every Cotuit ✓q Ma 02635 8/19/15 State- +nat page. City/Town „ _.. Zip Code Date of Inspection rat^+ 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:When filling out forms A. General Information on the comouter. use only the tab 1. Inspector: key to move your r g cursor-do not Michael DiBuono -- --- use the return - -._-- -.___ Name of Inspector key, DIBuono,Sewer and Drain,-,-,, ma I I Company Name - _. �I 8 Johns path --- Company Address - -- er�,�. S Yarmouth MA 02664 - City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B.Certification 'rY y ------ ------- I certify that l'have�personally inspected'the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Pusses ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority /..... . 8/20/15 Inspector's Signature D at e __.._- -- -- 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. Sins•3/1 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 P Y Page 1 of 17 • 4� Commonwealth of Massachusetts --,p Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \ a 91 Waterford Dr Property Address Herb Grossimon Owner Owner's --- Name- -.._ .__ ..... __".".._ .-.. - ---- information is required for every Cotuit Ma 02 8/19/wn -635_ -. 15 page. City/To -- _ 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: The system contains a 1000 gallon tank as well as a concrete Distribution box and leach pit. Home has been vacant for some time. DBox shows signs of hydrualic failure. leaching is holding water to within 12" of invert pipe. 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): t5ms•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form a. - Subsurface Sewage Disposal System Form - Not for 9 p Y o VoluntaryAssessments 91 Waterford Dr _. __ ... Property Address Herb Grossimon Owner Owner's Naameme---- information is required for every Cotuit-----._._.._.___...__._._-_-_._._- ...... page. -- ._. Ma 02635 8/19/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Flump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System-Conditionally Passes (cont:): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ms•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 " n. Commonwealth of Massachusetts ia� -- Title 5 Official Inspection Form hu-_ IW __ I- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t= 91 Waterford Dr Property Address Herb Grossimon Owner _ Owner's Name information is required for every Cotuit Me 02635 8/19/15 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '12 day flow 151ns•3113 - - Titles Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Titler 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \ A � 91 Waterford Dr Property Address Herb Grossimon Owner .— - Owwnene r's Name information is required for every Cotuit Ma 02635 8/19/15 __. page. CityrTown __.._..-_.._...__-. State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ - ® :w. Required pumping.,more-than 4 times in the last year NOT due ta,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. 151ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•.Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr Property Address Herb Grossimon Owner Owner's Name information is required for every Cotuit ___...._..._ Ma 02635 8/19/15 page. City/Town - - ion 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 t51ns•3113 7rtle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts :� r t r 5 Official Iris,,,� pectin form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments —/' \a /' 91 Waterford Dr - ---- ----------.----- Property Address Herb Grossimon Owner caner s Name _ _-... ... . ._... ... _ information is required for every Cotuit Ma 02635 8/19/15 page. City/Town State Zip.Code Date of Inspection. D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box and leach pit. Home has been vacant for some time. DBox shows signs of hydrualic failure. leaching is holding water to within 12" of invert pipe. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?"jhcludb'Ibundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 220_GPD __ _ Detail Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial 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•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System F -g p y Form Not for Voluntary Assessments -;: 91 Waterford Dr _ - Property Address Herb Grossimon Owner Owner's Name information is required for every Cotuit Ma 02635 8/19/15 State page. City/Town Zip Code Date of Ins 1.pection D. System Information (cont.) Last date of occupancy/use: 6/1/2015 Date Other'(describe below):'-_ General Information Pumping Records: Source of information: 6/8/15 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 I inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t51ns•3113 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 8 of 17 SEP-01-2015 03:11 From: To:15087906304 . Pa9e:2/3 Commonwealth of Massachusetts r� Title 5 Official Inspection Form _ 9 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 91 Waterford Dr Property Address ---• •—•-- Herb Grossimon Owner _.. _.._. ..._ - ..�. _ Owner's Name inFOrn'121iDn is require(i tar every cotuit — Ma 02635 8/19/15 page. City/Town State tip Code Date of Inspection D. System Information (cant.) Approximate age of all components, date installed (if known)and source of information: 20 years _ Were sewage odors detected when arriving at the site? ❑ Yes Q No Building Sewer(locate on site plan): Depth below grade: �$ feet "'- Material of construction: R cast iron ® 40 PVC ❑other(explain): — -- --- -_... Distance from private water supply well or suction line: - -- -•- - -.-- —._ feel Comments(on condition of joints, venting,evidence of leakage, etc,): System is-vented throught the roof. Septic Tank(locate on site plan): Depth below grade: 1 ft — - _..... feet I Material of construction: - i �concrete El metal ©fiberglass ❑ polyethylene (]other(explain) 1000 gallon y ` I t i If tank is metal,list age: _.___......... years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes © No i Dimensions; 1000 Gallon Sludge depth: 3" ISns•3ri3 Title 5 Official In SpAG90+I FWi11 Subyirface Sevr100 i).saoeel$raven•Page 9 of S Commonwealth of Massachusetts u- - — Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr Property Address Herb Grossimon Owner Owner's Name information is Cotuit Ma 02635 8/19/15 required for every .____... -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge,-to, m botto -of'outlet tee or baffle 24 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations; inret-and outlet tee or baffle condition,'structural'integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NA 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 151ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr Property Address Herb Grossimon -._-ame- -. ._. Owner Owner's N information is tuit Ma 02635 8/19/15 CO required for every ........___ __.. _. _ _ -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is hold' g 6' of water sWd /J 5. .. _L-._ ! � r Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): lilt T, Depth below grade: Material of construction.- E. ] 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 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - •'� 91 Waterford Dr Property Address -- Herb Grossimon - . . Owner Owner's Name information is required for every Cotuit _. Ma 02635 8/19/15 — ------- 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 Rotted and decay.e.d..., 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 is rotted and decayed_ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t51ns•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts - a, Title 5 Official Inspection Form \ / Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr Property Address Herb Grossimon Owner - - — - — -- --...-------- Owner's Name information is required for every Cotuit M_ a 02635 8/19/15 Cit page. Y/Town State Zip Code Date of Inspection D. System Information (cont.) Type. zi leaching pits number: 1 ❑ leaching chambers number: -- - - - ❑ leaching galleries number: — -- - -- - ❑ leaching trenches number, length: -- - ---- - --- ❑ leaching fields number, dimensions: --- -- -- -- ❑ overflow cesspool number: ---- -- ------ ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Signs of carry over and signso f hydraulic failure. 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•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection For p rl'1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \ mow 91 Waterford Dr Property Address Herb Grossimon Owner Owner's Name information is Cotuit Ma 02635 8/19/15 required for 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.): Signs of failure in both the DBox and.._le.a.ch pit 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.): t5,ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts al -- Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 Waterford Dr J V Property Address Owner Herb Grossimon information is Owner's Name - --------._- - _----- required for every Cotuit Ma 02635 8/19/15 page. cityrTown 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 I t5ins•3/13 1itle 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 17 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR j QUALITY ORIGINALS) I M A�C(, I DATA I BARNS T AB LC flocatione 97. Waterford Dt:ive village o Cotuit . aeptl— T 1000 Gallen Se{�L..IC, 'I'anit Owner_ Herbert Grossimon Pu[ ppm H I.STORY 5/11/12 1000 Gals li II rN r; 1..� Commonwealth of Massachusetts - Title 5 Official . Inspection Fora, - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \ � 91 Waterford Dr Property Address Herb Grossimon Owner - --- -- - Owner's Name information is required for every Cotuit - -- - _Ma_...._.. 02635 8/19/15 page. City/Town --_---------- ---------------------- - State Zip Code Date of Inspection Do System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ft 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: Perk test would provide ground water data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5,ns•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts _ rp Title 5 Official Inspection Form --11=i . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y j 91 Waterford Dr _........ -- ------------- Property Address Herb Grossimon Owner ._.... Owner s Name information is required for every Cotuit Ma 02635 8/19/15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary-D,(System-Failure Criteria Applicable to All Systems)""tompleted ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•3f13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 4. pFIME r Town of!Barnstable ' ` o Department of'Regulatory Services BARNSfABLE,Q: Public Health Division Date MASS. 0 v$ r639• �e 200 Main Street,Hyannis MA 02601 pr60 MAt a 13;1 Date Scheduled Time M. Fee Pd. 1 ;1G� G j Soil Suitability Assessment for Sewa e disposal ((J� r"�-"`�,�, Performed By: �`C�✓ tee— 5C IS- -?__Witnessed By: In LOCATION & GENERAL INFORMATION Location Address �� j- _/ / Owner's Name 11-/,er /� Address 1 LAJ--a-4,- 0! Assessor's Map/Parcel: Q�`p—00 Z d)0 Engineer's Name NEW CONSTRUCTION REPAIR. Telephone# -,S'Q -7j7--G176vg� J Land Use l Sid t Z- K AJa 14 L• f,, y Slopes(%) Surface Stones - Distances from: Open Water Body /Jj A ft Possible'Wet Area �� ft Drinking Water Well ft> is U Drainage Way N /L ft Property,Line '3 Q ft Other ft SKETCH:(Street name,dimensions of.,lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) y Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: I% Weeping from Pit Face / Estimated Seasonal High Groundwater I _Z— DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment _ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ i PERCOLATION TEST Date Time Observation Hole# C ' ` ^ Time at 9" _ Depth ofPerc 5-4t �$ CL(e-. rdviStS a4� Start Pre-soak Time @ l "'� Time(9"-V) _ End Pre-soak e7z95- ,,,. t' • . Rate Min./Inch 1 l $ 1 Kc LI Site Suitability Assessment: Site Passed Site Failed:. Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed'on Back------;--- i ***If percolation test is to be conducted within 100' of wetland, you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC F DEEP.OBSERVATION HOLE LOG Hole# pth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in,) (USDA) (,Munsell) Mottling (Structure,Stones;Boulders.. onsistency %Gravel)_ -33 t3 5 L a 12s1� — 3 501,A . v-5 Y 14 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency!%Gravel) s I.& (7- 5/4 Z C_ r"'t 5C-o'01 S DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consiste Gravel) =—T DEEP OBSERVATION HOLE LOG Hole# D pth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones`,Boulders. Consistency! i Flood Insurance-Rate Map: Above 500 year flood boundary No_ Yes 2L, Within 500 year boundary No-4 Yes Within 100 year flood boundary No_A�_ Yes el3th of Naturally Occurring Pervious Material oes at least four feet of naturally occurring pervious material exist in all areas observed throughout the a ea proposed for the soil absorption system? ^ 2v I not,what is the depth of naturally occurring pervtous material? Ctr,tificatLon I ertify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . e required tr ' g,expertise and experience described in 310 CNM 15.617. Signature Date .\ EVnCVERCPORM.DOC APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION__/ cam? m �� ,rr4 .0e/Vt�7 NO. /yLLAGE__ �'., �a.z . DATE_V 7- 1PPLICANT FEE ? ; ►DDRESS-__/6�_� �ZrC= Z3 CE�V'tt��✓��GL TELEPHONFyNQ. -77/-D�y�VNon- fundable) NGINEE ti ��,� _ TELEPH N/E NO ) . )ATE SCHEDULED c�_ `� Ll $ (Applic nt- s s ' nature) • . . . . . . O O O O O O . . . O O O O O . . O . . . ..O . O . O O . . . . . . . O . . . O . • . . . .'. . O O O . . . . • . O . O . . . O O . O A ceF.SSOR'S MAP tG LOT NO: SOIL LOG ''>UB-DIVISION NAME W.Allr 0-r 2D - � �. �. .� DATE -/4 IME 1 O iXPANSION AREA: YES NO y�L(p.(G- w�( CAP � ENGINEER DOWN WATER_PRIVATE WELL BOARD OF HEALTH telA-ti( /J J .7 2 5c0L EXCAVATOR. ;KETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation' tests, locate wetlands in proximity to test holes) NOTES: A � u� w 0.0 . 3 9 Al � VD�a> M00, q78 4-2)g, 0 / 33 !ERCOLATION_-RATE; _G--�4_IAJ l fWC ff— PEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: - zx,` 2 3 4 4 `�'� t��lLk p-A6. 5 8 ,�1.�fl 8 , 9 9 10 10 12 l u 4- "12 tN OF 13 Io � � 13. e 14 14 JA 15 15 IL so792 16 16 Qr�'�fC�STEa iUI`l't�t�L",-FOD ' B-SURFr,C Si,'riiGE: LEACHING'FIELD _LEACHING LEACHING TRENCHES JNSUITABLE FOR SUB-SURFACE SEWAGE. .REASON$f JOTE: ENGINEERING PLANS, MUST SHOW NUXBER. ASSIGNED ON PERC TEST APPLICATION )RIGINAL: . COMPLETED 'IN ENTIRETY BY P . E. A& RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT TOWN OF .BARNSTABLE LOCATION t-y W°tiC �ac QG�1� SEWAGE # 164 - 23 VILLAGE �-D�cJ°� ASSESSOR'S MAP & LOT,5'6-00D -VI V INS TALLEt'S NAME Si PHONE NO: pC �S C d -7 7 l —L&4-0 SEPTIC TANK CAPACITY LEACHING FACILITY:{,ype) c`�'�^ Q` Esi .e) (0 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATRR Q� f �D �()�1(lLt Cd, BUILDER OR OWNER �7 �l - DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I J I �� ' '�� ._ . . ..1 ' i `� , va M''` .v 2��g�� � ' �.Y}. No...O ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH fu/r ..............OF.... Appliratiun for Uiupuuttl Works Tonutrurtiun Permit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ....«Qom: �TV.._�/..�.. 7 . .a.C�. .....=D ........ ........C_© c 1 t....-------- ................................ .... tion NoIO r°.D. dX----..r�.Qs ° ...C, TW�Ot -� Own Address ««........._. a Y..'U..:..... .L.�1..�.—L....-•-•-•---•-•----.....--•--••......... ................ -=--��Ll`•�------.........-----••-----•---•-.......:.................. Installer Address �� V Type of Building Size Lot.....:......................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (Na) a Other—Type of BuildittgGl/(�(�D.�RdM . No. of persons............................ Showers (. ) — Cafeteria ( ) dOther fix ures ..................•---...---•..............----------..........................•--------...............---•-----....................---•--.........--- W Design Flow............... .....................gallons per person er,day. Totala daily flow........ .................... .... WSeptic Tank—Liquid capacity.JQQ0.gallons Length... ..�P... Width............... Diameter................ Depth.:. :y."... x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area.....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching areag2Y.5....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. 1...t.........minutes per inch Depth of Test Pit.....1 YY``.... Depth to ground water.....N 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....................•---•-••--•---..................---•--• •-=--•-----....._...-•---------......-------•-............_W.... O Description of Soil....0 3Q.�...._L'..........................................' - D 1-1— *3 �� l-` y" MIT. C619RS,1;" :t9�✓� -••.............................................. U ------------------------------------------- •----------- •------- ---------------- •----------------------- •----- .---------- .-------------------------- •----- ----------- • -------- -•-........ ---....- W UNature of Repairs or Alterations—Answer when applicable...........................:................................................................... --••-•••--••--••••••••••••-•••••----.....---•-•-••--•---•-----•-•-••••-•••-•---••-••........_...•--•-•••••••.............•---•••--•--•-••-••••••-•----•-•.............................--•--............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordant ith the provisions of LI'U 5 of the State Sanitary Code —The undersigned f ter agrees t ,pl4ee th em in operation until a Certificate of Compliance has been issued by the board of.healt / Signed.........`? --•• ----•-. ................. ....... Jul.. <.....j�....... Date Application Approved By............. ---- �..(. ..._........... ------ Date Application Disapproved for the following reasons:............................................................................................................ _.. ................••---.............----•.......•-•--........•----....................---.....................---......................••-•--•-•-•........._....._...._...............- ........... Date _ PermitNo.....�7` .r- - " ........................... Issued_....................................................... I � 2 THE COMMONWEALTH OF MASSACHUSETTS j 'BOARD -OF HEALTH Applkation for Disposal Works Tonotrudion thrmit Application is hereby made for a Permit to Construct (? ) or Repair ( ) an Individual Sewage Disposal System at: Loc545 0ation N -Addre r o Lot •o .......................................... • Owner Address - - f� l......... . .........GIJ ••-•-------•----•.................... ..........n.....-.. ..L-......-------•------•--•-••--••--•--............................. .. ........... Installer Address Type of Building Size Lot.................. . Sq. feet U DwellingNo. of Bedrooms......................... .Ex Expansion Attic a — __________________ p ( ) Garbage Grinder (,A/i) PLO Other—Type of Buildinga)aa&FX4Q Y/E No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .........--•----•-------•..........................................---------••-------------..._.........-----......................................... W Design Flow.............�_r ............gallons per person per,day. Total daily flow.........3 0..............._........gallons. WSeptic Tank—Liquid capacity-MpO.gaIIons Length... ?___ Width:_--5,' . Diameter................ Depth.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area .5_....sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Result Performed by..................•---.........................•-----....-•-.............. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..... �`�4.__ Depth to ground water..... fzq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to,ground water......................... p4 .........-•-••-•-------------••----•--..............---•--••....•-•-•-.............--••.........••--............ O Description of Soil... _... .7� L 6111t m C* 508s D tL `3c� W .......................... ....... --••---•-.........•.................... ...._._....-•----._..............---........-------- .............. ..... .......- .......6 Nature of Repairs or Alterations—Answer when applicable................. .{ .................................•--------------••-------•---•----•--..._..------------........--•---.....-•------------------------------=-------•--------------------------------•-•--.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordanceowith the provisions of TITL-_ 5 of the State-Sanitary Code— The undersigned f r'ffier agrees irbt�to place th l •stem in operation until a Certificate of Compliance has been issued by the board of li t Signed......... � !t1 ...�_......... af `7/. .. .... Date Application Approved B Date Application Disapproved for the following reasons---------------•-•--••---••----•---------...-----------...--•-----•---------•--......_------. ---.......... ' c ................................••-•---...---•------••---•-------•---•-••------------•-•---•--------.......----------•---•-•---------------•-----••-.....•••• '......................................... Date Permit No..... .c�: a-31 = _.. Issued--•--....----- -----.....•....................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. ... .........OF..... 0 t!7/j6 Tntifirate of Toutpliattre THIS IS TO CERT FY, That the Individual Sewage Disposal System constructed (x) or Repaired ( ) by.. (/ 2 ;(i`' ..... •---•-----•................•-----.....-•-•----................-------•................. at.... •..............................................•---... has been installed in accordance with the provisions of TITL _ 5 of The State Sanitary Code as described' in the application for Disposal Works Construction Permit No......._.._.?........C; a/_... dated..................:............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Cl DATE......... 9' ? _ '" ••- .. ... Inspector Inspector .... .... ............................................ THE COMMONWEALTH OF MASSACHUSETTS _ 'e BOA RD/�O,F HEALTH` No...ld..9'...r� /. ....... ... .. ...... Fly . 5....... -... Disposal Works Tunstritrtiun f rrmit Permission is hereby granted. -'`! ....Gf? . J --•-----•-------•-------•............... ......................... to Construct O or Repair ( )Lanp Indvdidual Sewage;Disposal t ystem atNo.... ..............( .. ��•l tlz�/ f l trJ '75 . ---•-•--........-------•---••---------------•-..............._..._------........ Street QQ as shown on the application for Disposal Works Construction Permit NoV:'.�-:3.�... Dated.......................................... Board of Health DATE "---_..........................................._ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � � Applicationis hereby ouule for u Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal � ' ^*' � ......................... ....................................................--'--------------'------ u� �" -- - . '_ ........ "d& -======�'�-_-_-' z��u� Type of Buildifig Size feet [hv�l6��--��o. of B�dr000m----_.—_�=�----_—.- Attic ( ) Grinder ( ) Other—Type of Building --- No. of persons........................... Showers ( \ -- Cafeteria ( ) � ~~ Other fixtures � Design per person per day. Total daily flow''' 04 Septic Tank—Liquid ............gallons .. Diameter................ Depth................ Disposal Trench--No..................... Width.................... Total ................... Total leaching area....................sq. ft. Seepage Pit No..................... Diamctcr--.----- Depth below inlet.................... Total leaching area.-'------xq. ft. Z Other Distribution box ( \ Dosing tank / ) ~~ Percolation Test Results Performed bv.......................................................................... Date........................................ � Test Pit No. l................miootesperincb Depth of Teat Pit.................... Depth to ground watec'---_--_. cX4 Test Pit No. 2................minutes per inch I)eot6 of Test Pit.................... Depth to ground watcr—.--,----.. 0 ---_.--_-----'-'-_--_'-_--------___-__---_---_____--_-_______'- Description of _________._________._______________ __----_'--. -' ....................................................................................................................................................... � The undersigned agrees to install theuforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU: 5 of the State Sanitary [ode—The undersigned further agrees not to place the system in operation nudl a Certificate of Compliance has teEff-i*ped�tg��ard of health. � 5 _____ ~ Date Application Approved By'----- ,�_�- Date Application Disapproved for the following reasons:.............................................................................................................. --_-------_-_-----.-_—_----'--_------'-------'_-'-_--------------_---._--_-----_----_-_---'-- u"te | Date / No..-0- Fzc$..... 5....... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................O F........................................ Appiiratiun for Disposal Works Tonstrurtivaa ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal SyAWK at: ......... ..... .. ..................... .....--• ••--....-••••••••...... • •.......-•-••••-••••...--•-••.......--•--- - o ess or Lot No. a •- �'•` - •-----. ..... .�....... -----•—T--,.... . .T.. \.�.f'K.wc.�.,.•�. -......-----' .:.-V- .......... Installer Address UType of Building Size Lot............................Sq. feet �-, Dwelling No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building 00Q' :....... No. of persons............................ Showers ( ) — Cafeteria ( ) 0 Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity......_.....gallons Length................ Width................ Diameter---------------- Depth................ xDisposal Trench—No................ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No............ ........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 01 .--•----••-•------------------.............................................................................................................................. Description of Soil....................T................................................................................................................................................... x v •-••-•-•-•-•---•----------•-----••-•---••••-•---••----••-----•-•-•...-----•-•---•••---•-•••---••-•--••-••••••--•---•----••-•----•--•---••••----•-•.................................................... ------------------------------------- •----•-----------•......•-----------•-....------•-••----•---• -------------------------- --- U Nature o airs or 1 r > n s hen app �.. .'...__ _ � ... C.. ----Ae -------------------- ----------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT LE 5 of the State Sanitary Code— The undersigned further agrees not to place t e system in operation until a Certificate of Compliance has �'1�'e'n""i�su and of health. Sig " "e ,""�,"-'-'-"....------. •--- Date Application Approved By--...------. S�7,,,,,....: �.. ---•---- j Date Application Disapproved for the following reasons----------------•-----------•---•----•.......................................................................... ••-•---••.......•---••••-•-•••-•-•--••••••-•-•-••....---••••••---•••-••••-•••---•.......--•...---•••.....--••-•-----•--•-••--••-•----------•-•--•-----•-•------•-------•••-......•----------•--•--•••--- Date Permit No......-i? ..._.---- "' - • Issued---...----•....................................•--••••- Date Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C�rr�ifirtt#r a�f f�uut�li�aatre THIS IS TO CE , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.............. "Y.PQ.".......• .... .....e'D�r'!`^.... ..........�.------------------------..... --....---------......--------------------.....---.......------......... at•••-•-. •L��?..... ...........f:m-eld..../jei. Install ��.r. .`'ate:=-�- has been installed in accordance with the provisions of 1'! . 5 of The State Sanitary Code as described in the --application for Disposal Works Construction Permit No....9 .. .... ......... doted................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUtICTION SATISFACTORY. DATE...........lam .......... Inspector� ��� i%!�/ G THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No...B!_.".. ...................OF..... . ........................................ FEE...........r. �i��ru�� urk,� �uay��raivat �erutit Permission is hereby granted.........a_:... ......- --•--- . --- --------------------••------------------...-•-- to Construct ( � or Repair an Individual sewage j�i�pos:l System r Street as shown on the application for Disposal Works Construction Permit o.-p" --- Dated.......................................... w Board of Health DATE................. ---?---•-- --- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS """"0 I!MAW'"�' "APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS y , LOCATION/ L X10-(Ve NO. VILLAGE ��.,�c a ', DATE ?9, APPLICANT 4DmJ6 FEE'' •— — ADDRESS /( -� /Zr� r3 GE�I�- ✓«�L.� (Non fundable ' TELEPHON .27/zoa 9, ,(Non- c �,L. ��� _ TELEPH NE' NO. DATE SCHEDULED__ 1�7 (App1ic nt� s :s ' nature) O O O O O O O . a O O O O O O O O O • • • O O a O O O • •:.. ...O ...: O • . . . • .•. . O O O .. . . . . O O . . .p a O .I . . ... M.M.QR,S biAP �. LOT NO: f,. - SOIL LOG.: SUB-DIVISION NAME_ 1 � �.�21J -(� cl._� DATE � TIME 0 �o EXPANSION AREA; YES NO G j�OLI�U ' wti( C�Pam) ENGINEER TOWN WATER PRIVATE .WELL 'Jr`�f tl�fti�l $OARD OF HEALTH VATO EX - ... .. , .:: ,.d h...,.+e.,- :.�a ..Ji.:..xe.rs� .�ia',:Gr..e-ems_... v-'M...,..:+an..a,«.... K s+^�".;b,.M,S— �.y,.z:....�...�..,'„c......,..at• ;s...,.. SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests,' locate. wetlands in proximity to test holes) NOTES: N ao 3 9 V� r/V P iN - \ / ` t j A +` if ' !�t! [ fl�Cc-tf— �-- - - -_PERCOLATION RATE: ---�-- - . TEST, HOLE NO: ELEVATION: f -'-'-.'TEST HOLE NO: µ ELEVATION: 3 4 4 r CA4'25 .� •t _ , 9 9 t 4 10 12 4.4 of 13 1�o I,c� z(L_.'' �� 13 ti 14 r 14 JA 1516 15 IL 16 SUITABLE-FOR• uUB—S Rrss .0 vr�rVsaVP,. . •LEACHING`?FIELD LEACHING LEACHIN TRENCHES . UNSUITABLE FOR SUB—SURFACELSEWAGE. ,REASONS: NOTE: ENGINEERING PLANS MUST, 'SHOW NUMBER,,.ASSIGNED ON PERCt,TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY_P,, E. YAND RETURNED 'TO BOARD- OF HEALTH COPY RETAINED BY APPLICANT, , N -� Tel � Ro��e co OCUS 'C 'fir S 88'05'49" E x 36.4 e T o _ '133.41' N 3 p M CD 36 _ 0 Pp erf 6 0 V Crystol Ridge Rd Dr Q� 40.1 LOCUS MAP NOT TO SCALE LEGEND 56 --EXISTING CONTOUR x 56.82 EXISTING SPOT GRADE car. �s 56 PROPOSED CONTOUR 4 W EXISTING WATER SERVICE LOT 6 ✓ G EXISTING GAS SERVICE 48,492 ±SF U UNDERGROUND WIRES - --` � PARSEL ID: 056-002-010 ® TEST PIT BENCHMARK 44.1 44.2 x 45.9 \ Air& \ x 44,42 Z \ t O W ^"� \\ TP-2 I 0 rn �\ 4T�.90 ' \ r O Of lawn `.;. 00 EXISTING LEACH PIT x 0 �� � .-N \ � TO BE PUMPED & FILLED �\ 1 +,46A7 STAKE i W/SAND4AN0_.ABANDONED 0_ _. .X sole. .\_x -`, _ . '9 - - EXISTING SEPTIC TANK ` o`" �`:�' x 46.94 (TO REMAIN) 53.26 50.8 + ti TOP OF TANK, EL.=50.19 s3.2z � O +�4g al i INV.(OUT), EL.=48.86 � �� x '�4-5x �087 BENCHMARK ' 54.53 54.13 . ' AC OUTSIDE COR./BOTT. STEP x 50.29'-_ EL.= 50.87 (Assumed) DECK PAI VED 5502. il.gl oz \ DRI VEWA Y:- x so.29 EXIST)w 50:3 55s36 : GARAGE HOUSE(#91) z :55.24 T.O.F.=56.Ot ---_ 55,63. •` N N ' S5.39 J WALK 54.43 --�q LAMP 55. 55.36 \ _-6 581 58.57 59.14 59,33 59.48 (5�-- ------- 61.21 _--- 60.31 61.04 60.52 AMP OF �qS Q6:00 1.00 �\ 63.2 Q f9 61.13 x 1 60.77 W 0 o PETER T. s McENTEE 61.27 N 80.1 61.22 3 27 �/ , CB o CIVIL "' edge 62.66 W Of 61.12 ��- No. 35109 ^ /7-r T jT� Dpvement RFC/SjER�����c� f-a 1 -/=�l/, /�J O 60.42 _ ------- . 1 �-(7 jl. � --- .J J 59.19 -�I V.� Engineering by: SCALE DRAWN JOB. No. PROPOSED SEPTIC UPGRADE PLAN Engineering Works, Inc. 1„=30' P.T.M. 251 -15 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET No. 91 WATERFORD ROAD MARSTONS MILLS MA (508) 477-5313 1127X16 P.T.M. 1 of 2 Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 I NOTE: TO PREVENT BREAKOUT, FINAL GRADE SEPTIC TANK SHALL NOT BE AT, OR BELOW, EL.=44.5 INSTALL RISERS & COVERS OVER INLET & FOR A DISTANCE OF 15' FROM THE EDGE OUTLET AND SET TO 6" OF FINISH GRADE PROPOSED D-BOX OF THE PROPOSED S.A.S. INSTALL RISER & COVER PROPOSED S.A.S. SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND T.O.F=56.0t SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT F.G.,EL.=54.2t ' F.G. EL.=50.8t F.G. EL.=48.0t F.G. EL.=47.0 to 47.8t MAINTAIN 2% SLOPE OVER S.A.S. . . Ali 7YJilSvy`�,.vAvy7 L = 19' L = 5' � r 0 S=1% (MIN.) p S=l% (MIN.) 2" LAYER OF 1/8" TO 1/2"4"SCH40 PVC 4"SCH40 PVC 6" DOUBLE WASHED STONE 10"I . s mr.3 a (OR APPROVED FILTER FABRIC) 1 a^ aaaaaaa EXISTIN 48" UQUID aaaaaaa 3/4" TO 1-1/2" DOUBLE LEVEL ADD ✓J . PROPOSED 4' 4.8, 4' WASHED STONE GAS BAFFLE INV.= 44.27 _ INV.=44.10 INV.=48.86t D-BO EFFECTIVE WIDTH EXISTING-VERIFY 3 OUTLETS INV.= 44.00 EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN NOTES: I)- CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & TOP CONC. ELEV.= 44.8f INVERTS EXITING HOUSE, PRIOR TO INSTALLATION. BREAKOUT ELEV.= 44.50 ease INV. ELEV.= 44.00 eases 2) D-BOX SHALL BE SET LEVEL AND TRUE TO aaaaaaaaaaa GRADE ON A MECHANICALLY COMPACTED SIX aaaaaaaaaaa BOTTOM ELEV.= 42.00 INCH CRUSHED STONE BASE, AS SPECIFIED 4' 2 x 8.5' = 17.0' 4' IN 310 CMR 15.221(2). 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0' 3) INSTALL INLET & OUTLET TEES AS REQUIRED. PERVIOUS MATERIAL 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' (MIN.) ABOVE G.W. AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. LEACHING SYSTEM SECTION BOTTOM OF TEST PIT, EL.=35.8 = SEPTIC SYSTEM PROFILE SOIL LOG GENERAL NOTES: DATE: OCTOBER 30, 2015 (REF#14,893) 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL EVALUATOR: PETER McENTEE PE(SE#1542) BOARD OF HEALTH AND THE DESIGN ENGINEER. WITNESS: DAVID STANTON R.S. HEALTH AGENT 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS ELEV. TP-1 DEPTH ELEV. TP-2 DEPTH OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 46.9 A 0" 46.8 A 0" 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR SANDY LOAM SANDY LOAM TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 10YR 4/2 10YR 4/2 DESIGN ENGINEER. 46.2 B 8" 46.1 B g" SANDY- LOAM- -> .--- - SANDY-LOAM- --- 4. ANY-CONDITIONS ENCOUNTERED,DURING--CONSTRUCTION DIFFERING 10YR 5/6 10YR 5/6 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 44.1 Cl 33" 44.0 Cl 34" ENGINEER BEFORE CONSTRUCTION CONTINUES. PERC 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. MED. SAND MED. SAND 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 2.5Y 6/6 2.5Y 6/6 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 35.9 132" 35.8 132" THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING NO GROUNDWATER, PERC RATE: <2 MIN./IN. CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS REFERENCE PERC P-7285, 4/27/89 IN SAND IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 25\y INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND I PROP 1 IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. S, A.S/M DESIGN CRITERIA N NUMBER OF BEDROOMS: 3 SOIL TEXTURAL CLASS: CLASS I 0; DESIGN PERCOLATION RATE: <2 MIN/IN in (0.74 GPD/SF LOADING RATE) DAILY FLOW: 330 GPD DESIGN FLOW: 330 GPD GARBAGE GRINDER: NO DECK LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF .74 GPD/SF EXISTING SEPTIC TANK: 1000 GALLON CAPACITY GARAGE FXIS77N PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLETS HOUSE(1f91) USE 2-500 GALLON LEACHING CHAMBERS IN SERIES r.o.F=Ss.of SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F.TOTAL AREA:..............................................................471.2 S.F. / SEPTIC LAYOUT DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD'! Engineering by: SCALE DRAWN JOB. No. PROPOSED SEPTIC UPGRADE PLAN Engineering Works, Inc. N.T.S. P.T.M. 251-15 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET No. 91 WATERFORD ROAD MARSTONS MILLS MA (508) 477-5313 1/27/16 P.T.M. 1 of 2 Prepared for: D.A. Brown, Inc., P.O. 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