HomeMy WebLinkAbout0042 DOLPHIN LANE - Health 42 Dolphin Lane '
Hyannis
A= 268-193 . .
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Commonwealth of Massachusetts 3
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,
;-� 42 Dolphin Lane
Property Address ;
Noura.Milardo r0
Owner Owner's Name
information is Hyannis Ma 02601 10/20/2018 -�
required for every H y �
page. City/Town State Zip Code Date of Inspection
5.dr
lxl
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 A. Inspector Information Sl* c 3y�,-)--
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
Company Address
Centerville Ma 02632
Cityrrown State Zip Code
508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com 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
10/20/2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If'the system 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 does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
ps Title 5 official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis annis Ma 02601 10/20/2018
page. City/Town 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:
The dwelling located at 42 Dolphin Ln Hyannis is served by a Title V septic system consisting of a
1500 gallon septic tank, distribution box and 16 Bio-Diffusers. The system was found to be in proper
working condition at the time of inspection.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. City/Town 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. Cityfrown 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
L
Commonwealth of Massachusetts
p. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. Cityrrown 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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
u 42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. City/Town 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 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. Cityfrown 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 gpd
Description:
Number of current residents: 0
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
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 8/2018
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
u
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. Cityrrown 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
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Miiardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. Cityrrown 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:
system installed 6/1/2011
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks or blockages. Vented through roof
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
4io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. City/Town State Zip Code Date of Inspection
D. System Information {runt.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
0 concrete ❑metal [I 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: 1500 gallons
Sludge depth:
Distancefrom-top of studge to-bottom of outlettee or baffle
3'
Scum thickness
2°
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet
and outlet covers are on risers.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. City/Town 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is Hyannis Ma 02601 10/20/2018
required for every y
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.):
Distribution box was level and in good condition with no rot. Water level was even with 4 outlet inverts
with no signs of past backup. Cover is on a riser
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
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: 16 Bio-Diffusers
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields 'number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.TMI2016 Title 5 Official"Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18''
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�r
a 42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis annis Ma 02601 10/20/2018
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. consists of 16 Bio-diffusers in a 25'x11.5'field. No signs of past saturation, vegetation was
normal.
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� G Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
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
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. Cityrrown 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
r 40 0 C�A
1 �
� ? 3
3 Z.
l3� Zs
AZ z1
i32 Z-7. r
0
A3 3
r�3 1z,37-
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� 42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. Cityrrown 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: 12'+
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:
Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Dolphin Lane
Property Address
Noura Milardo
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/20/2018
page. City/Town 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.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
l
'OWN OF BARNSTABLE
LOCATION J ��® P/�,Le4�(��SEWAGE#
VILLAGE SSESS/OR'S MAP&PARCEL '?
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(tYP e)�� / '(size)/19.�' �'C�
l�
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE: /
Separation Distance etween the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet-of leaching facility) Feet
FURNISHED BY '
I
j .
s � �
No. 1.—, 3 Fee 0_6
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISIO61 :VOWN OF 6ARNSTABLE, MASSACHUSETTS YeS
application for V�tID 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location.Address or L t No. 0 Owner's Name,Address,and Tel.No..
Asses or's Map/ParceI
Installer's Name, dress,and Tee o Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
r
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 51 gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank�j'�� /�j-(,�� �jH Type of S.A.S. d
Description of Soil 3.2 gar
Nature of Repairs or Alterations(Answer when applicable) ae Aw D D --5
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. �\
igne Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. /l "-�to Date Issued
i°
/ P `
No. / (9 _ , Fee 166
` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISIOk?!TdW,N! ARNSTABLE, MASSACHUSETTS Yes
01pplitation for BispdsaY 6pstem CollstCUCtiou vermit
Application for a Permit to Construct( ) Repair(V Upgrade( ) Abandon( ❑Complete System ❑Individual Components
Location Address or Lot No.��. '�� ` Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. MA"- f� �p -Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building �j No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ''j j� gpd Design flow provided .5 �� Q gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tanklf, /-5"Q(j' � � Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �f� Gf� /-S'OD T h SA q
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
i'
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of j
Compliance has been issued by this Board of Health. ---�
Signed\//. Date
Application Approved by Date
Application Disapproved by Date
'i
for the following reasons
'a
Permit No. Date Issued
J `^
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Complianre
THIS IS TO CERTIFY,that the On-sit age Disposal system Constructed( ) Repaired( Iel� Upgraded( )
Abandoned( )by llit�� G f
at L� has been constructed in accordance
�'- �/with the provisions of Title Sand t e-for- isposal System C r�ruchon�'ermit No. C�1/-14 dated �` � dj/
-Installer Designer
#bedrooms Approved design flow gpd
�1
The issuance oft is permit sh 11 not 'e construed as a guarantee that the system�wil"�l fim 'on de 'gned.
Date n Inspector
No. �L�11 / (U Fee
THE COMMONWEALTH OF MASSACHUSETTS
_�, PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
*pstrm onstructlon permit
Permission is hereby granted to Construct( ) Repair( !i� Upgrade( ) Abandon(t )
System located at y -5,j 112 //
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction mu t be compl ted within three years of the date of this per it.
- C2 Approved by iL
i
r
Town of Barnstable
�TME Replatory Services
Thomas F. Geiler,Director
snaxsrescs. +
IMAM g Public Health Division
ATF639. Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: (all A Sewage Permit# Assessor's Map\Parcel2 113
Designer: Installer:
Address: X Address: �!JC
On � was issued a permit to install a
(da e ,�(( T� (installer)
septic system at `'e2- V�L� *1J L� based on a design drawn by
(address) l
dated S Z`1 l
(designer)
1 certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation or the
distribution box andior septic tank.
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.
OF MAss9
o D R N ✓�
E
(Installer's Signatur l o: 40
SAN I TAR��'�
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Health/Septic/Designer Certification Form 3-164doc
i
Town of g d P#
Department of Regulatory Services• -� Public jIealth Division Date �✓/ °l J
/
�wtexarAVM
„rose.
sb y tee$ 200 Main Street;Hyannis MA 02601
Date Scheduled Time�_ Fee Pd.
I
,Foil Suitability Assessment fog age Disposal
Performed By. Witnessed By: ,
i
LOCATION & GENERAL INF,ORMATION
Location Address•.42 DOLT i tJ L>fJ r ' Owner's Name S�
Address PL% (A
.1.,
: Hy �1 SP �,H k,)r1 w mk
Assessor's Map/P4rcel: 2�9-/�C!3 I Engineer's Name
( i
NEW CONSIRU�'iION REPAIR �— Telephone#
Land Use I I/ �� Slopes(915) �4 0' Surface Stones e—
Distances from: Open Water Body 2Ud ft Possible Wet Area '� ft Drinking Water Well
Drainage Way 10O ft. Property Linc w ft Other ft
ns of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
SKETCH:(Street name,dimensio
11 90- @t
1 '
)IMd1011d3S
--� WE)OOS'I 'd0Xj I
----------------------
7,77
G'-Hl Vi I
I I 0 i
T 11 T0'
o 10 .
0 O fs. IG
_ II 9 l_L1 11 tj .II W
C1. I
0
I-LJ
5
0
13ci'^ I i 0 dln3nRi0 7�43ned
I or
t
LO ;l 9NI1S01X3
n'
Parent material(geologic) �Q I �_'"' � Depth to Bedrock
Depth to Groundwaier. Standing Water in Hole:' N i Weeping from Pit Face
Estimated Seasonal Nigh Groundwater N/A
DtTERMINATION FOR SEASONAL HIGH WATER TALE
Method Used: I in.
Depth dbpemed standing in obs.hole: _ in. Depth to Sall motor : tt
Depth toiweeping from side of obs.hole: in: Groundwater Adjustment
_ A .factor Adj.Croundwaterl evel..,,,e,
Index Well#_ Reading Date: Index Well level -- dI
PERCOLATION TEST . Date TIMp
Observation I Tithe at 9" ..
Hole#
CoQ�l
Time at G" ......-----
Depth of Pere
v Time(9"-6") .
Start Pre-soak Time.@
End Pre-soak
l t.ig
Rate MinJInch
Site Suitability Assessment: Site Passed _
Site Failed; Additional Testing Needed(YIN)
Original:.Public i e;iith Division Observation Hole Data To Be Completed ' Back—
***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.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders.
Consistenc %Gravel
0''-4'' _ �.� NIA.
4il— it lNt L4
31�1_ W, C n 2 5 6
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)
Oct ¢q toyi2i4/7 /J
3e-443"
Ptd, 2.S
DEEP OBSERVATION HOLE LOG Hole# NIA
Depth from Soil Horizon Soil Texture Soil Color Soil - Other
Surface(in.) (USDA). (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders.
Consisten ra I
Flood Insurance Rate Mau:
Above 500 year flood boundary No— Yes
_ Within 500 year boundary No Yes_
Within 100 year flood boundary No
Y Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious Material exist.in all areas observed throughout the
area proposed for the soil absorption system? -
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on �� (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was performed by me consistent with
the requir (raining,expertise and experience described in 3.10 CMR 15.017.
Signature l6,, l Date 1
Q:\.SEPT10PERCFORM.DOC
LOCATION SEWAGE PERMIT NQ.
VI`,LLAGE
INSTALLER'S NAME i ADDRESS
I
R U I L D E R OR OWNER
Al
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
pa -
0
o
W
i
t
W
s
1 -
HYANNISPORT
LEGEND
—� PROPOSED CONTOUR
® PROPOSED SPOT GRADE o
—— 98 —— EXISTING CONTOUR z
°
+ 96.52 EXISTING SPOT GRADE rz
W— EXISTING WATER SERVICE _ °�
SITE
EX15TING CE55PO17.29
TEST PIT m
(NOTE 10) m
39 ft.
-----------
40 I —---— v
CRAIGVILLE BEACH ROAD
I
LOCUS MAP N.T.S.
II 1 j j 1 GENERAL NOTES:
.�SOT 0 :1
/ / I 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
AREA = 1837,1 sf + —
1 38 BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
O I I OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
40\\` DRIVEWAY O Vwd I LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:
q�ED j i I' — 310 CMR 15.405 (1) (B):
bw 1) A 0.61 FT. VARIANCE FROM 310 CMR 15.221(7) TO ALLOW LEACHING
��— el
,out
ce ��� i TO BE 3.61 FT (MAX) BELOW GRADE VS REQ'D 3 FT. (VENT/H20 PROVIDED)
O I o 0 0 0 ,� j 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
,� I o TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE/�i j o DESIGN ENGINEER.
B
1 O 0 I , I o 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
I o 1 O=' �l I ,� 1 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
v 1 1 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF .of Oz �
O C A 10 ft I ,. I HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
III 11 �O ®TH-2 i� 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
-- ➢ II I, TH-1 � 11 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
II I 2 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
I i CONSTRUCTION.
10. EXISTING CESSPOOLS TO BE PUMPED, CRUSHED AND REMOVED PER TITLE 5.
-{ I 39 FILL WITH CLEAN MEDIUM SAND. (COMPONENT LOCATIONS PER TITLE 5 INSP.)
I 1��-` _________ 1 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
/ I 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
I I PROP. 1 ,500 GAL �,� N I AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
II 1 SEPTIC TANK _ __ _ ' 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED
I / - J 14.5. THE DESIGN OFB 4 SYSTEM DOES NOT T (UNLESS SPEC. OTHERWISE)
' _________________ 1 E SCH 40 ® 1/8"/FT (UNLESS S E)
I 1
182.06 ft
II l-_--------- ------ - - - - - - - - - - - - - 38 FOR THE USE OF A GARBAGE GRINDER
IS
16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING
rn 17. PROPERTY IS MW IN ZONE II OR NITROGEN SENSITIVE AREA.
I 18..TEST HOLE SHOWED POCKETS OF SILT LOAM, SOILS MAY VARY,
ENGINEER TO INSPECT AND CERTIFY BOTTOM OF EXCAVATION PRIOR
OF (�s� PLAN TO INSTALLATION.
q�yG BENCH MARK PROPOSED SEPTIC SYSTEM UPGRADE PLAN
o � TOP of CONCRETE SCALE: 1 in = 20 f.ii�R BULKHEAD CORNER 42 DOLPHIN LANE HYANNISPORT MA
)F 1
0. 1140 ELEVATION = 40, 11 20 0 20 _�o Prepared for: Safton
BARNSTABLE GIS DATUM M' ti�g
'PF6/STE�� - 0 10 20 �d Engineering by: Surveying by: SCALE DRAWN
NITAR�P� L DARRENM MEYER,R.S. ECoTech Env. 1"=20' DMM
' PO BOX 981
EASTSANDW/CH,MA02537 508 367-8097 DATE: CHECKED SHEET NO.
S `t c )
506-362-2922 05/24/11 DMM 1 of 2
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:34.89
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. I
T.O.F. EL.=40.40 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER;INSPECTION PORT OVER OF
OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. V NT F.G. EL.=39.25t F.G. EL.=39.0f F.G. EL: 38.5t F.G. EL: 38.5 (MAX.) ARRE
C E
1• N 1140
L = 10"± 9" MIN COVER/
O S=1% MIN. 36" MAX COVER L =2� TEE L = 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.)
(MIN.) ® S=1% MIN.) ® S=1% (MIN.)
INITAR�a
4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC ,
,. 6 11.2" TO
INV.-36.74 48"LIQUID INV.=36.49 INVERT
LEt'n INV.=35.0
GAS BAFFLE PROPOSED 4 ROWS OF 4 UNITS AT 6.25'/UNIT = 25'/ROW
INV.=35.20 DB-5 INV.=34.50 SOIL ABSORPTION SYSTEM (PROFILE)
PROPOSED 1,500 GALLON SEPTIC TANK
EXISTING SEWER OUTLETS RESTORE VEGETATIVE COVER
8 EL.=36.98
EL.=37.65
BACKFILL WITH CLEAN PERC SAND -75"
B TO TOP OF CHAMBERS
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING `: '
PIPE INVERTS PRIOR TO CONSTRUCTION BREAKOUT=TOP ELEV.=34.89
2) TANK AND D-BOX SHALL BE SET LEVEL AND INV. ELEV.= 34.50
TRUE TO GRADE ON A MECHANICALLY COMPACTED BOTTOM ELEV.= 33.56
SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN EXISTING SUITABLE
310 CMR 15.221(2) 2.83' MATERIAL
5' MIN. ABOVE BOTTOM OF
3) PLACE SANITARY TEE IN D-BOX AS SHOWN. T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' = 11.32 76"
4) INSTALL INLET & OUTLET TEES AS REQUIRED (7.36' PROVIDED) USE 4 ROWS OF 4-16" HIGH CAPACITY (H20) PROFILE
BOTTOM OF TESTHOLE EL.=26.20 - ADS 16008D BIODIFFUSER UNITS-NO STONE
SEPTIC SYSTEM PROFILE TYPICAL SECTION
N.T.S. N.T.S. 16"
11
DESIGN CRITERIA SOIL LOG P#: 13279
NUMBER OF BEDROOMS: 3 BEDROOMS DATE: MAY 18, 2011 f 34" �
SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. SECTION END CAP
WITNESS: DONALD DESMARAIS, BARNSTABLE BOH
DESIGN PERCOLATION RATE: <2 MIN/IN 16"" HIGH CAPACITY H-20) BIODIFFUSER UNIT
DAILY FLOW: 330 G.P.D. Elev. TP-1 Depth Elev. TP-Z Depth
DESIGN FLOW: 330 G.P.D. 38.20 0" 38.25 0"
4 LOAMY SAND 1 A MODEL 16" HICAP
GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) LOAMY SAND 10YR 4/3 10Ya a 3
PROPOSED SEPTIC TANK: 330 X 200% = 660 GPD, USE PROP. 1,500 GALLON CAPACITY 37.95 4"1 37.95 4" LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
B i B EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
LEACHING AREA REQUIRED: 330 = 445.94 S.F. LOAMY SAND LOAMY SAND DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
( ) 10YR 6/4 1GYR 6/4 SIDE WALL HEIGHT 11.2"
.74 35.62 C1 31't 35.58 C1 32" OVERALL HEIGHT 16"
DISTRIBUTION BOX: 5 OUTLETS (MINIMUM) SANDY LOAM SANDY LOAM OVERALL WIDTH 34" 4640 TRUEMAN BLVD
PRIMARY S.A.S. 2.5Y 6/6 2.5Y 6/6
13.6 CF HILLIARD, OHIO 43026
USE 4 ROWS OF 4 - 16" 160OBD ADS BIODIFFUSER H2O UNITS-NO STONE 34.53 44"I1 34.67 43" CAPACITY
C2 C2 (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC.
BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF BIODIFFUSER) PERC • EL. 33.20 MEDIUM SAND MEDIUM SAND I
(BIODIFFUSERS) 16 UNITS x 6.25 LF x 4.73 SF/LF = 473 SF 2.5Y 6/4 2.5Y 6/4 PROPOSED SEPTIC SYSTEM/SITE PLAN
DESIGN FLOW PROVIDED: 0.74(470 GPD/SF) = 350.02 GPD > 330 GPD req'd 26.20 144` 26.25 144" 42 DOLPHIN LANE HYAN N I S PO RT MA
PERC RATE <2 MIN/IN. ("C" HORIZON) Prepared for: Safton
NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN JOB. NO.
DARREN M.MEYER,R.S. EcoTech Env. NTS D.M.M.
• 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 pO BOX 981
to conduct soil evaluations and that the above analysis has been performed by me consistent with the DATE CHECKED
requirements of 310 CMR 15.017. 1 further certify that 1 have passed the Soil Evol. Exam in October, 1999. EASTSANDW/CH,MA02537 (508) 367-8097 SHEET 508-3822 2922 05/24/11 D.M.M. 2 Of 2