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HomeMy WebLinkAbout0183 DUNN'S POND ROAD - Health 183 DUNNS POND ROAD,HYANNIS 05 A= 270 0 i j I d. I� I i O� /� �-7�a .. C!os No.-- ! -���---_1(0 2�— Fwa.............................. THE COMMOI-Vk&"L",TH OF MASSACHUSETTS BOARD `OF HEALTH TOWN OF'BARNSTABL.E Alip iratioaa for Diinpootai Vork.5 Tomatrur#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair (0,t+an Individual Sewage Disposal System at: ..IF& AO 4)AN'Iu1.S 0'/,3 D G c4�4-•f1 Z—,'— Dot J Location-Address or Lo N ..... . Owner `�1.. Address a �d�l U LV 1/ �i �o�� �' zk7 y F W/� ✓� . s'✓� /1-L� ....................... •-•--•--•----•-.................... -------------- ..... _..... --••-r �• :_. Installer Address UType of Building Size Lot............................Sq. feet ►., Dwelling— No. of Bedrooms---------------!.�......._....._._.__...___Expansion Attic ( ) Garbage Grinder (—) AJ p aOther—Type 'of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- - W Design Flow-------------------- ---------------.__gallons per person per day. Total dais flow............ --------------------gallons. Gd Septic Tank—Liquid capacity_ 0--gallons Length. " ___ Width---._•.. ._'_.... Diameter................ Depth... < W x Disposal Trench—No. .....-1'.:..___. Width..... ------- Total Length-22 Total leaching area....................sq. ft. Seepage Pit No--------- ........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box .( '). Dosing tank ( ) 0-4 Percolation Test Results . Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit----_.__---..-----__ Depth to ground water...•.................... Test Pit No. 2................minutes per inch ' Depth of Test Pit_.......:--------- Depth to ground water..._____.-_____--____--- --••-------•--••............................................•----•-•--•------••--•----........------......................................................... ODescription of Soil........................................................................................................................................................................ x c, .---•-----------------•-----------------------------------------------•------------------------------------------- -----------...---------------•--------------------------------------------------••••-• w -------------------------- •----.......-----------.....-•-•-------------------------•••--•------------------------------------------------------------------ UNature of Repairs or Alterati ns—Answer when a�p licable.__1 ... _A-.._ ..�`��."T��-:�_. 77W-Fare a--• ....................... J -. .X.. s.a': ac . _.... la ................i.. Agreement: j The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the. State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant as en is e y�hoardh. G� Signed --7 ��K� ............ ............ Application.Approved By ---- -------- ------------------------------_------..................................................................................... ...............Dare.................. Application Disapproved for the following reason r- ------------------- ----------------------------------------------------------------------------------------------------------- Dare Permit No. r.....A&..2.6.................:. Issued .........._.......... - .......................Dare _ -............................. ...... No. Fizaf...3.G............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirtttion for Diopogal Workii Tonotrnrtion runfit Application is hereby made for a Permit to Construct ( ) or Repair (I �,4 an Individual Sewage Disposal System at: 1,� 00iP ojs VvN.O GZOA-0 /�/1sJDui J .........................................•------------......----•----------------------....._,...- -• --....---•-•......-•••._................. Location-Address or Lo No l�Ll 1/« .S/ .0,, ,V, 0 ►lij 19 GA/Z 4-+IJ fl 1-. '"/1--f 4T� .............................X t r =..........................................--.......................................................................... -------- ............................. .... �•ner Address a .................................................Ulm Q Ltl 1/ 'L G,.JS Co j LjAA,`r�'9 2U� �lil , v✓I i l,cS o/lil q- . ................................................ ----•----------••-.....-•-...•--------:-----------••-•••--...---••-----------t•-------•---•------- Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.............../_��//-------_!------------------Expansion Attic ( ) Garbage Grinder AJ b Other—Type 'of Building _...........................'yNo. of persons---------------------------- Showers ( ) — Cafeteria ( ) a d Other fixtures --------------- .................... 'a,. Design Flow...................5. S_._._._.._._.gallons per erson per day. Total daily flow------------%.yU.._.....______._... Ions. W g g P P P Y Y WSeptic Tank—Liquid capacit_f Pn_galIons Length_`_-_ Width_.__ �F_--.--. Diameter---------------- Depth.. _ ... x Disposal Trench—No. .................... Width.....5.....`..:. Total Length J- -AM Total leaching area....................sq. ft. Seepage Pit No.........._...------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ,( ) _ Dosing tank ( ) '~ Percolation Test Results Performed by------------------------------------------ ............................... Date........................................ Test Pit No. I----------------minutes per incli Depth of Test Pit...----------------- Depth to ground water........................ (Z Test Pit No. 2..................minutes per inch Depth of Test Pit------------------- Depth to ground water........................ 9 ----=-----------------------•---------------•••-•--•-•••--••------•••---------•--•--........._------......................................................... 0 Description of Soil--------------------------------------------------------•-•------- .----------------------------------------------------------------------•-------. x U ..............................7.._._..._____._____._..____....._.__.___.__.__........___.._....._____.._._...___.._._._.____.._..__....__._____.._.__._.....___._.._.__...__._.__.__........____._____... (sl — U . Nature of Repairs or Alterations Answer when applicable �'�1:- :__.�f __�S "�ZC...� _;.. c . I S-- U " , �- S: ,.J x ......--..�...------...... ........ - -------- :d. �.x. �---!_�... / -----ZV✓------e_Tizy---;v/C------1-1................... Agreement: , I W/ t -V%% a 8 V 64-r-l` Theaunclersigned agrees to-install the aforedescribed Individual Sewage Disposal System in accordance with the pf6tils.ions Of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the syste't n operation until a Certificate of Compliance/'?as en is ed y the board of health. �>9 '� _ Signed J Application,Approved By .._...>..ti / O -----------------.............. ....-----.—....................ire ... Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------- . ..._.. . ............ ._... .._.........-----------..: .................�.. . ------------------------------------- -------------- ------------------ Perm' Dare t No. ........ - ------- l�n.. w----------------- Issued e' 7 Dare THE COMMONWEALTH OF MASSACHUSETTS 2 7© BOARD OF HEALTH TOWN OF BARNSTABLE C'elrtif rate of C�om lt�xrzcP THIS IS TO CERTIFY at the Individual Sewage Disposal System constructed ( ) or Repaired (� ��-i?it �rJS/,-,2 vU, ,,.) ) G--------------------------- n, r at .- 1 1J _.... U,AoJ�-- L- J r -�i...- - /vV N.. has been installed in accordance with the provisions of TITLE4,of The State Environmental Code a desc ibed in the application for Disposal Works Construction Permit No. ��--._ r_Z-. --- ------- dated ...___ --�----2 ..?1.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON STRUED AS A GUAR A�TEE THAT THE SYSTEM WALL FUNCTION SAT SI F.A►CTORY. DATE P.... -------------------------- - - Inspect r d a y .-.t...R THE COMMONWEALTH OF MASSACHUSETTS y/7� BOARD OF HEALTH ff TOWN OF BARNSTABLE No .ram.../ n-? FEE..--•-••�........... Ripnial Nimbi Tonotrurtion antit Permission is hereby granted----------------- G -,.•-, -G_W'�_.._.____... !v._ �G'J ------------------------- ....... to Construct ( ) or Repair (P)C) an Individual Sewage Disposal System atNo.----...---•---•---•-----------------•------. alQ -� Street as shown on the application for Disposal Works Construction Permit No._":7_5-__/e�P�-Dated.__/ o15 --........ 0��� Board of Health DATE .----�---•--•--- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, �' JOtO LO� hereby certify that the application for disposal works construction permit signed by me dated- 9� , concerning the property located at /Y3 b y'1,J Ns 'f2OMO 4A3 1-1-101-JAr3 meets all of the following criteria: C, • There are no wetlands within 300 feet of the septic stem proposed P sy `- • There are no private wells within 150 feet of the proposed system septic stem P v TThe observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed There are no variances requested or needed. SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. Cb /41ct�S� t 8�3 D v",Jljaaa a i BORTOLOTTI CONSTRUCTION, INC. 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM N Address Prop ,y0 hs A OJQj`J� Date of Inspec� M Owner arcs PART A — CHECKLIST h�` ca CHECK IF THE FOLLOWING HAVE BEEN DONE: 9 PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. P/AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP. E SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON—INTRUSIVE METHODS. THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms No of Current Residents Garbage Grinder yek Laundry Connected to System Seasonal Use NON RESIDENTIAL Calculated flow WATER METER.READINGS,IF AVAILABLE: GALLONS Pu Records and Source of Information: S (�gt//. pel 1,9RIK— SYSTEM PUMPED AS PART OF INSPECTION?" Y PUMPE = GALS IF ES,VOLUME D Reason for Pumping: TYPE OF S EM: Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes,attach previous inspection records, if any) Other.(explain) Approximaatt ag f. Lcomponerns. Date install nown. S rc��lofglatio e SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? C:J r ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) E TIC Depth below grade: Dimensions: Material of construction: 4.eflooncrete Metal FRP Other} Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle rye Scum Thickness d Distance from Top of Scum to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle Comments: Q DISTRIBUTI N X: Ol` /Pq. le DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: f PUMP MSER• IVO Pumps in working order? Comments: IL ABSORPTION SYSTEM SAS IF NOT PRESENT,EXPLAIN: TYPE: �." 30 ants: a / n S CESSPOOLS: Number and configuration Depth—top of liquid to inlet Invert Depth of solids layer Depth of scum layer Dimension of cesspoolI Materials of construction Indication of groundwater Inflow(cesspool must be pumped) Comments: PRIVY: Materials of constructkm Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) : SKETCH OF SEWAGE DISPOSAL SYSTEM: INCWDE TIES TO AT LEAST Two PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS.WITHIN 100' d c z ooQ 3 8 _ y (j 3 �3� BN" Z � 66 I7 DEPTH.TO GRO<UNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION:OR APPROXIMATION: CA 1.44f A y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? All Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfikration? tank failure imminent? Is any.portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh(cesspools&privies only, not the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality-analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D - CERTIFICATION INSPECTOR: 'ROBERT J.BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508)771-9399 CERTIFICATION STATEMENT I CERTIFY THAT HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS:TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION, THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER,FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH,ORTHE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 1.5.303.:THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA'SECTION OF THIS FORM.. INSPECTOR'S SIGNATUREr DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop 3 s Date of Inspec6 A/s Ma 7 arce�. Owner ��� N CHECK IF THE FOLLOWING HAVE BEEN DONE: PART A — CHECKLIST WN mI 1/PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYST S RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN IN 1�0E THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. �— THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON—INTRUSIVE METHODS. ti THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms 3 No of Current Residents o Garbage Grinder yt'�' S Laundry Connected to System Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pumpi g Records and Source of Information: ! SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF SYSTEM: Septic tank/distribution box/soil absorption system s/ Single Cesspool Overflow Cesspool Privy Shared system (if yes,attach previous inspection records, if any) Other(explain) Approxj1hate age of all components. Date installed,if known. Source of information.QQ SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: 1170 Depth below grade: rrDimensions: Material of construction: Concrete Metal FRP Other} 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 Comments: DISTRIBUTION BOX: IV61 DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: PUMP CHAMBER: 410 T—Pumps in working order? Comments: SOIL ABSORPTION SYSTEM (SAS): IF NOT PRESENT,EXPLAIN: TYPE: Comments: CESSPOOLS: Number and configuration �_ ',J� }r 4't:'�j Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool L�_' 6-140 Materials of construction t 1,K g" Indication of groundwater inflow(cesspool must be pumped) As 57L a2Cdoha'S 41 nP O S e PRIVY: Materials of construction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' tsE DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: AN/OX 145. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y-yes N-no ND-not determined.Describe basis of determination.If"not determined",explain why not.) V Backup of Sewage into Facility? / Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? I Within 50.feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? /V- Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SrrE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY