HomeMy WebLinkAbout0019 BONNIE BRIAR DRIVE - Health 19 Bonnie Briar Drive
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TITLE 5 41r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: #19 Bonnie Briar Drive
Osterville,MA,MA
Owner's Name: Joseph&Susan Shortsleeve
Owner's Address: #685 Boston Post Road
Weston,MA 02493
Date of Inspection: 08/14/07
Name of Inspector: (please print) Mr.Carmen E. Shay
Company Name: Shav Environmental Services,Inc.
Mailing Address: 185 Ashumet Road
Mashpee,MA 02649
Telephone Number: (508)-539-7966
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system:at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
XX Passes /t 7 v��'t,C
?� ` - .�
Conditionally Passes �( I,
o All�.=ilrii7
Needs Further Evaluation by the Local Approvin uthority zi E.
f Fails o SHAY Z�
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Inspector's Signature: Date: 8/14/07
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 ofthe t
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the app oving ;
authority.
Notes and Comments
No evidence of backup in system components,Opened Leach pit cover-2 feet effective depth rem ining.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph&Susan Shortsleeve
Date of Inspection: 08/14/07
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
T . .,.., 2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: . Joseph& Susan Shortsleeve
Date of Inspection: 08/14/07
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION continued
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph&Susan Shortsleeve
Date of Inspection: 08/14/07
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes ' No
XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
XX Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
XX Any portion of the SAS,cesspool or privy is below high ground water elevation.
XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
XX Any portion of a cesspool or privy is within a Zone I of a public well.
XX Any portion of a cesspool or privy is within 50 feet of a private water supply well.
XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
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
M the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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.
., 1 . 1 11 1,,.,,— 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph&Susan Shortsleeve
Date of Inspection: 08/14/07
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
XX Pumping information was provided by the owner,occupant,or Board of Health
XX Were any of the system components pumped out in the previous two weeks
XX _ Has the system received normal flows in the previous two week period')
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up'?
XX _ Was the site inspected for signs of break out
XX _ Were all system components,excluding the SAS, located on site'?
XX _ 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?
XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
XX _ Existing information. For example,a plan at the Board of Health.
XX _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph& Susan Shortsleeve
Date of Inspection: 08/14/07
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: Unk.
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COM MERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: None Available
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
XX Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
June 10, 1980-original,- per Owner&BOH Records
Were sewage odors detected when arriving at the site(yes or no): No
T 1 . — 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph&Susan Shortsleeve
Date of Inspection: 08/14/07
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction: cast iron _40 PVC XX other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 8"to Top of Tank
Material of construction: XX concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 5' deep x 5'wide by 8' long (1,000 gallons)
Sludge depth: 4.0'
Distance from top of sludge to bottom of outlet tee or baffle: 2'
Scum thickness: '/4 inch scum laver noted
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: Measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. Baffle present at inlet
end. Outlet Baffle present and in good condition. Liquid level equal with outlet invert. No Leaks Noted.
GREASE TRAP:_(locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
.,. ,, 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph&Susan Shortsleeve
Date of Inspection: 08/14/07
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): D-Box Present—one outlet,no evidence of significant carryover.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
14
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Page 9 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph&Susan Shortsleeve
Date of Inspection: 08/14/07
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
XX leaching pits, number: I
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.): No evidence of hydraulic failure of septic tank or of leach pit. Top of leach pit is 24" below ground.
2' effective depth available in leach pit.
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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph &Susan Shortsleeve
Date of Inspection: 08/14/07
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
Swing Ties:
Bonnie Briar Drive
A- Tank In—2 F
B- Tank In—40'
A-Tank Out—26'
B-Tank Out—43
Water Line A—D-Box—28'
B—D-Box—46'
A—Leach Pit —30'
B'—Leach Pit —63'
Exist House
A B
Deck
O
Septic Tank
O (1000 Gal.)
Leach Pit
D-Box
O
10
Page 1 I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #19 Bonnie Briar Drive
Osterville,MA
Owner: Joseph& Susan Shortsleeve
Date of Inspection: 08/14/07
SITE EXAM
Slope
Surface water -'/2 mile+/-
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 30 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked with Quadrangle of USGS Map.
Per USGS MAP PLATE 2:
Elev. of Ground=Elev.-30
Elev. Of Groundwater=Elev.-5 Feet
Elev.Of Bottom of Leach Pit 8 Feet below grade or Elev.22
Therefore: 22-5 = 17 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well MIW29 (Zone c): 3.5 feet
Adjusted Groundwater Separation=22'—8.5=13.50 feet between bottom of pit and adi.groundwater
Grade=Elev. 30 feet
Pit#1
Septic Tank
Bottom of Pit=Elev.=8 feet
Adj. Groundwater=Elev. 8.5 1
74-
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETTS ,A
EXECUTIVE; OFFICE OF ENVIRONMENTAL.AFF ROS
DEPARTMENT OF ENVIRONMENTAL PROTE T JN�
C j.
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION 5 Q Q
Proper(% Address: 19 Bonnie Briar Drive O U
Osterville,MA
Owner's Name: Margaret Shortsleeve \l
Owner's Addres,. C/o Joe Shortsleeve v
683 Boston Post Road, Weston, MA 02493
Date of Inspection: July 8 2002
Name of Inspector: Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis, MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
I certify that 1 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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv�tem
VPasses
Conditionally- Passes
Needs further Evaluation b) the local Approving Author it)
Fails
Inspector's Signature: �,, �, Date: 7/6 /Da
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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.
Notes and Comments
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
****This report only describes conditions at the time of inspection and under the conditions of use at that
~ time. l his inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 pace I
1
' Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of Inspection: Margaret Shortsleeve
July 8,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that anv of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are.indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to a replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Boa of Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the_ for the following statemei . If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank ether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure ' Imminent. Svstem will pass inspection if the
existing tank is replaced with a complying septic tank as approved the Board of health.
'A metal septic tank will pass inspection if it is structurally sou ,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break t or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settle r uneven distribution box. System will pass inspection if(with
approval of Board of Health):
ken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The syste required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspecti if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of Inspection: Margaret Shortsleeve
July 8,2002
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 Frill pass unless Board of Health determines in accordance with 3.10 CMR 15.303(l )that the
system is not functioning in a manner which will protect public health,safety and the a -ironment:
— 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 r}t rsh
i
2. System will fail unless the Board of Health (and Public Wat Supplier, if any)determines that the
System is functioning in a manner that protects the public he th,safety and environment:
_ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a
surface %%ater supply or tributary to a surface wate upply.
The system has a septic tank and SAS d.the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank an AS and the SAS is %sthin 50 feet of a private water supply well.
_ The system has a septic t• - and SAS and the SAS is less than 100 feet but 50 feet or more froth a
private water supply well•'. Method used to determine distance
"This system pass if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and vol a organic compounds indicates that the well is free from pollution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure c ' eria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 Bonnie Briar Drive
Osterville,MA
Owner: Margaret Shortsleeve
Date of Inspection: July 8,2002
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_✓ Liquid depth in cesspool is less than 6'below invert or available volume is less than %day flow
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.
N-3 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
&M 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
suppl) well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
/uy (Yes/No)The system fails. 1 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 de ign flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to'each of the following:
(The following criteria apply to large systems in addition to the criteri above)
yes no
the system is within 400 feet of a surface drinkin ater supply
_ the system is within 200 feet of a tributary a surface drinking water supply
the system is located in a nitrogen s itive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply ell
If you have answered"yes"to any stion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lay system has failed.The owner or operator of any large system considered a
significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner ould contact the appropriate regional office of the Department.
4
r
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of Inspection: Margaret Shortsleeve
July 8,2002
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
P..;:T11w, information was provided by the owner. occupant, or Board of 1 icahl,
_. . ._V/ Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection?
V _ 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 Nvith information on the proper
maintenance of subsurface sewage disposal systems'.)
The size and location of the Soil Absorption System(SAS)on.the site has been determined based on:
Yes no
✓ — 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(3)(b)J
5
Page 6 of I l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of inspection: Margaret Shortsleeve
July 8,2002 FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ,3 3 U
Number of current residents:_3
Does residence have a garbage grinder(yes or no): Rio
Is laundn on a separate selvage system (yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no):6
Seasonal use: (yes or no): YES
Water meter readings, if available(last 2 yearslrsage (gpd)): 01 c YD�oo s oo_ yZ� o 00 4uo N s
Sump pump(yes or no): io
Last date of occupancy:
COMM ERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.)._ _ '
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 syste (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: �_7/I 2 q 6 7/t 5/ y �., , !3o N
Was system pumped as pan of the inspection(yes or no): /w
1f yes, volume pumped: gallons- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components. date installed(if known)and source of information:
i-hS4- 11c� o GA 80 S- Lip 1f
T
Were sewage odors detected when arriving at the site(yes or no):ivo
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of Inspection: Margaret Shortsleeve
July 8,2002
BUILDING SEWER(locate on site plan)
Depth b du%% grade: 18" +
Materials of construction: _cast iron �40 PVC ✓_other(explain): 1 ;,1,a t�✓ f„ V�
Dkianct• fron. prnate water supply well or suction line: lv/,g Comments(on(on condition of joints, venting, evidence of leakage,etc.):
C. In J :YD✓hfA c,(-L ✓ �... -Ln '><—'
SEPTIC TANK: __�_/(►ocate on site plan)
Depth below grade: _I
Material of construction: concrete_metal_fiberglass Polyethylene
—other(explain)
If tank is metal list age:— is age confirmed by a Certificate of Compliance(yes or no)'_(attach a copy of
certificate)
Dimensions:
Sludge depth
Distance from top of sludge to bottom of outlet tee or baftle: a ,8
Scum thickness: wo m c
Distance from top of scum to top of outlet tee or baffle: Nv s c
Distance from bottom of scum to bottom of outlet tee or baftle: No S• �;,,
flow 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.):
C:��_�-v+.�.___, a.�_' V„ c.r-�- ���,� • h w u.- 1-c.� � __o._�-.c,(t:.�. /1lo__c v� a.-c�.._s.i._9
G .'.a(� S-� L.�cw.3 _v_....c� G.n (•L to/�__H a 4-
—T
✓•'M -7ti• S -r'Z yy t
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal fiberglass_polye lene_other
(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
from bottom of scum to bottom of outlet tee o aftle:
Date of last pumping:
Comments(on pumping recommendations,inlet• d outlet tee or battle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leaka ,etc.):
I
7
f
Page 8 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of Inspection: Margaret Shortsleeve
July 8,2002
TIGHT or BOLDING TANK: (tank must be pumped at time of ins tion)(locate on site plan)
Depth below grade: _
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions: _
Capacity: gallons
Design floe. _ gallons/day
Alarm present(yes or no):
Alarm level:_ Alarm in working or r(yes or no):
Date of last pumping:
Comments(condition of alarm and t switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: —
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.):
O W G. � `T��r.`Jl /e.y�1 e��./•.t ., e•�o I-L �.. c� O v c1t � w � -� G u r c/l
IO ��ytivc _/t c— e
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition pumps and appurtenances,etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSM
ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of Inspection: Margaret Shortsleeve
July 8,2002
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS nut located explain w•h).
Type
leaching pits. number: l - L 'X ' L
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.): n
✓�' 1 I.JaS .- Sti`�'��. . Lco.c t:. p1. F �.J S��To✓n.A S. 1-F
�-'/'/!'1 .4.. CI T i V1 s i'f t L'I7 c) :�f 61_.�_ •.�. I r 4 -C.•� .,0 10
I. s llyv�r l : � •! -�c�_' .
t..J c v� �✓n e a- f +1, •,c o h S f---,3 4-
CESSPOOLS: (cesspool must be pumped as part o/inspection)(I te on site plan)
Number and configuration:
Depth--top of liquid to inlet invert:
Depth of solids la)'er: _
Depth of scum ]a.\er.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes oXno)::
Comments(note condition of soil,signilure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions: Zre,
Depth of solids:
Comments(note condition of soil,signs of hydraulil of ponding,condition of vegetation,etc.):
9
- Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Bonnie Briar Drive
Osterville,MA
Owner: Margaret Shortsleeve
Date of Inspection: July 8,2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building1/0
3
63'
• �_ fox
' l0
Page l l of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
19 Bonnie Briar Drive
Owner: Osterville,MA
Date of Inspection: Margaret Shortsleeve
July 8,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 3 0 feet Adjusted high ground water elevation feet
Please indicate(check)all methods used to determine the high ground %%ater elevatiow
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation!tole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: M 7 , Y.o a�j
You must describe how you established the high gr/olund water elevation:
u u _1.—�L
Ct'j C�K.i u 6 7 d. 7 G.H rt �1 v.v� W 4}-.t✓ t�
Ae
is
� u U
a o
1�. 6
31. 9 '
poi°ter. (ki y 5. . ..14 —
y.t '
II
TOWN OF BARNSTABLE
LOCATION 1 QQ 1 QO\e. SEWAGE # bo—
uILLAGE � V \1Q ASSESSOR'S MAP & LOT��
INSTALLER'S NAME&PHONE NO. k%T kNjt�,\MZ-5
SEPTIC TANK CAPACITY DCD6
LEACHING FACILITY: (type) (0 (size) ( }ow
NO.OF BEDROOMS 1
BUILDER OR OWNER C,C
PERMTTDATE: 4—a 50 COMPLIANCE DATE: (- 1 o " 0,
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
tJ on site or within 200 feet of leaching facility) A Feet
Edge of Wetland aFCqv%4X1N
aching Facility(If any wetlands exist
within 300 feetle-
facility Feet
Furnished by ' ykfyf�� �
y3,
3o'
yE r I
63 /
r
L-0CATION _ DSEWAGE PERMIT NO.
•fir J i3��/i �r' �3 ��
� .yCJ yt'::
VILLAGE
os?ter ��cc �►,� �5 0 32
INSTALLER'S NAME D ADDRESS
S UILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ���d-
� „
; .
/��s� _, .
� �
L/ 1�
3 Z�-
U
G3 ��
-- �. _ __-- r,___
_-:-
No................� %=- Fim.... .d.
THE COMMONWEAL1'H dir MASSACHUSETTS
BOARD OF HEALTy
...-........0F.-. .., .. . . ... ........................
ApplirFation for Uigpas al Morks Tontrurtion ramit
Application is hereby made for a Permit to Construct (r✓) or Repair ( ) an Individual Sewage Disposal
systew t
...... = = .. 1.......... �,.uz ...............r.�L .. . s///.
L tion- ss i 9
�// ...
- •- .. i ��............... or t.AO..... ........._..._......
caner - .Address
W -- ....
.-------- ....
Installer Address �'��
U Type of Building Size Lot__A(ff. _--Sq. feet
Dwelling—No. of Bedrooms...... .................................Expansion Attic ( ) Garbage GrinderPL4
Other—Type of Building No. of persons............................ Showers — Cafeteria
d
Design Flow----- . _......._ .gallons per person per day. Total daily flow_... _3.4__..!TTl...._%.._..
W g P P P Y Y 7 gallons.
WSeptic Tank—Liquid capacityl40_f(9gallons Length............... Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width..... _. ._.._..._ T9pal Yngt h .___........_...... Total leaching area...............0....sq. ft.
Seepage Pit No...../d CQ_.. ........ et.................... Total leaching area..-..: -.sq. ft.
z
'—' Other Distribution box Percolation Test Results Performed b lfW ._.._�_ -----•- Date...? / `1� .........
( Dosing to
Test Pit No. 1__- .;L---minutes per inch Dep z of Test it____________________ Depth to ground water------------------------
Test Pit No. 2..... .........minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------I---- ----•2 t_............)....
Description of Soil.......°`....... . - --- •..:--- 1 ==G% 2 .T7
x
U
w
UNature of Repairs or Alterations—Answer when applicable................................................................................................
........................................................•.........................................•.............................•......................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIL- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe .............
--.....................................
. ............D e....----------
Application Approved BY----- cs•- -... /L'�---- .............•---... ...' 7` �
Date
Application Disapproved for the following reasons:-----••------------------------•--------------------------------------------•--•------------------......-----...
i
....................
•----------
----------------------------------------------------------------------
---------------------------------------
•-------------------------------------------------------
Date
PermitNo.......................................................... Issued..... ---• f--a----- ®...............
Date
No................'. Fizz.... ...,✓
w.
THE COMMONWEALTH b-F MASSACHUSETTS
BOARD OF HEAL H.
4ptiration for Disposal Works Tnnstrurtiun Vrrmit
Application is hereby made for a Permit to Construct ( r Repair ( ) an Individual Sewage Disposal
System at•0
cam..? `�.....'r'.'..... C.J
... /l�....._..------•• •,�dd.Fess -._....-•----•------- •-•--or Lot No. .....................................
.ti.........Loc`a ion IA
..".•...s!�:'�:'.^'"?..:' .:!cC:4's. ....................y[.?r"`'n. dSt+�3 :so„-r,�„fa<""-�"......... ._..__.............
.caner - Address
W `" /. sti!;n!i.�. S` ....---••------•---...--•...... ............... `� � tr�.....:..
a --•--•....._--._ ....... ----------------------••
Installer Address
Type of Building Size Lot... s: feet
U Dwelling—No. of Bedrooms...... .................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
� _:.._ lions-per erson er da Total dail _--•••:---�=__.1�..._____..
W Design Flow.,_..�. -.--•---.. .. ga P P P Y Y •? _ gallons.
WSeptic Tank—Liquid capacitytKA_dgallons Length................ Width................ Diameter................ Depth................
x Seepage Prt No------- -- et ------- D° To engt)e.................. Total leaching area....................sq. ft.
Disposal Trench—: o... ex
-- ' _..._••-•- I t - apt if l'o filet......--•........... Total leaching area_ 4.2`.sq. ft.
z Other Distribution box,( ) Dosing to ( )
Percolation Tesf Results ' Performed by._ t.: _._._ �_ ...................... Date..._F/I_} '' ?......__.
Test Pit No. 1.._. .. ,...minutes per inch Dep of Test it_________________`. Depth to ground water........................
a
Test Pit No. 2..... .........minutes per inch Depth of Test Pit.................... Depth to ground water.........................
O ••••M• -• I....... I. ...
..I...... . . -------------
Description of Soil....:_-" Gf•"•.� a• --�p...... x =- -
x
W ------------------------------------- .......... .. .........................................................
0 Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------_----_---•-------••_••_-____---•-.
------------------ .••. ••• ........----_-•--
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The.undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe .....•-__---• . ••-•--•------•-------•-----•----•-•-.....•-----•-••-•......•••••• ..........................--•--
11
Application Approved By....... =. . -- ...
-�,`% v/-�4. •---....._.: i��-- `_ ---------
Date
Application Disapproved for the following reasons---------------------------------------------------------------•----------------•----------••-----••••...__•-----
--•••--------••••-------•----••••------••-•--.......•---••-••-------•---•-•---•-•-------•......---•••--••-••---•-----••--------------••--•-•-•-•---••••-•------••-•-------•---•••....--•--••--•---------
Date
Permit No............. .. ' Issued --=
..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Z........... .....OF...., ,.,.r : ..........................
Trrtif iratr of- ToutpliFanrr
THIS IS TO CERTIFY, That, the Individual Sewage Disposal System constructed ( or Repaired ( )
by '' .+�....._..... ................................................. ...........................................................
rIrls ller r__� r a
... -.�- -
has been ins tilled in accordance with the provisions of l ,r2,•of The State Sanitary Code as des ib�d in the
tS e/ Gr
application for Disposal Works Construction Permit N ...._.._.__________________ da.ted.__..!r�::...��.__ .----........_......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION 5ATISFACTORY.
DATE............ --••--------- ---------------- ,Inspector--•---- _______ L-
nkh, _____________ _____ .......................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /
.' ? ..OF. / .,., ... „�.�` ....................... ,..
............. ��. .....
No..............1 FEE--- C..
Disposal rks permit
Permission is eby granted....... ! •--- ;�`,_..".. �----.....----•----------------------•---------..•....-•--_...---•---------
to Construct (� or Repair O,an Individual SewagerDlsposal System
at No. �r+r_'r��!`J �'/*- -�;.� - . t< ....................................... .........
V Street
as shown"' on application for Disposal Works Construction Permit-N _____ ___ _____f Dated.._.�`_�' ...............
............ ..... � -_ -----------------_
DATE......... _".'2.p-__�.............................................. Board of ealth
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
Uo GAtz$nGE Gtzt�.tn�
�E-PT'1G T ltC = 330,. (SO % * 495 6.P.D.
USA- l OC>Ci 6A,L.
S�ISPoSAL PtT - USE t Dcxn� G&J--. loci
Yo
St= &xg
Ed 63=. )c I .o = 50 G,.R D. g
TOTAL -DSS16KI = 42S G.t?D. J>
TOT&L 'C>eit L�-f t=Low =
3�6 Pp. �} f
PCWC-DL&Tl0LJ Z&TE CILI ZMIQ• 02 L1:SS. - S6dn,c
lei
T�sT
tuv•q ,U
Goal d'Pve loco iuv
Z _ SuBSur� -Box p Sepnc
Wv r I�O Tia�1K (�
l 000 �fG'o IWV.. wv 9`.3 •s,
Q PIT s
• Went .;
u WAfa1CD
f� STow,t_
CSQTtFIaD pLbT PL.4.V-1
Lf L oCAT I o z`J
Nv wA rl� 3 .2 5r •�0
GGIZTtt=-( TI-4AT THE �PC�P, WJELL, 51.10.juQ Pt--At1i R����c►.iGE '
%4r,-Ztzms-i Ccw%PLVS W/t-rIA TWG: 51D�.t_t►-�� �T— c� � /�
Aut> SETL.,ACK I` -:QUICEME.►-ITS of T►+e
-toww or-- 36?p-►J5`,19 LE . ?u4Q 3 4 Z•Eu R Y: 6kgU
to c dye, I .
vATc 3 Z B A.XTt=Vz I uet= t Qc-
REGIS M FSD "Wo 5UZ.va-fo
Ile, UOT 'LASC� vtr� AN OSTF-v-V%L_1L- a A,CASS.
1NSteJ.�nL�•t i �,Uc:�iL�{ * T"C CFI:,w✓<<, 'G'40WLr-> AF�PL.i GAt-.tT'
tik�r c u•:.cc� rc, v)r=TecM►►4C Lnr t_IWe'