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HomeMy WebLinkAbout0055 CRYSTAL LAKE ROAD - Health 55 CRYSTAL LAKE Rpe�OSTERVII,LE A = 146 195 i' TOWN OF BARNSTABLE . L-OCA i ION J� Cc`(S4 rt t /2 SEWAGE # --� VILLAGE t7 S �'J � '�� ASSESSOR'S MAP & LOT 1KU_ t4s INSTALLER'S NAME&PHONE NO. e w dh S L (SQB/ Ll a B -a Ke 3 SEPTIC TANK CAPACITY do S 41 LEACHING FACILITY: (type) -1 X 1 000 S ( D 0S (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: , Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3 `/ 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 W e (lt r r ., � _ ll ` 1 �� _. `U ��o J tJ y COMMONWEALTH OF MASSACHUSETTS- EXECUTIVE OFFICE OF.ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5, OFFICIAL INSPECTION FORM NOT:FOR.VOLUNTARY ASSESSMENT_ S SUBSURFACE SEWAGE DISPOSAL SYSTEM'FORM PART A CERTIFICATION Property Address: 55 Crystal Lake Road Osterville,MA 02655 'k " Owner's Name: Arthur McCarthy Owner's Address: _ Same R. ECEIV�p Date of Inspection: n: Augz+s t 21 2001 r, i Name of Inspector:(Please Print) James M Ford JUL 2 9 Z001 Company Name ' ' ' James M Ford �' { °f ,a , KTOWN OF'.. . s 4 N BqR ST Mailing Address.` "" 'P.O.'BOx"49 ° � ':Y " Map:14 x HEAL DE ABLE Osterville,MA 02655-0049 Parcel: 195 DEPT. Telephone Number 508 862-9400 CERTIFICATION STATEMENT' I oertify that I have personally inspected the sewage disposal system at this address and that the information reported below is true;accurate and complete 'of�the time of the inspection.k'-T'l e.mspection'was performed based'on my training and experience in'the proper function and maintenariceof on site sewage disposal systems. I am'a DEP approved system'inspector pursuant to Section°15:340`of Title 5(310 CMR 15.000): The system: ✓ Passes Conditionally Passes N Further Evaluation by the Local Approving Authority Fai s � t Inspector's Signature: "Date: August 22, 2001, The.system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this i Ispeotion. 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 origirial'should be sent to the system`owner and copies sent to the buyer,jif applicable,and the approving Notes and Comments77 Y T ... YJ...S{gLr i•`K.E � iti�w'f+. V..� - _ {t L.4.+a:+ E � s'rceporf only describes conditions at the time-of inspection and under the conditions,-of use at that time. This inspection does n"okiddie'si how the system will perform in the"future under the same or different conditions of use.: t Title 5 Inspection Form 6/15/2000 page 1: ' s. Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ . PART A CERTIFICATION (continued) Property Address: 55 Crystal Lake Road Osterville MA , r Owner: Arthur McCarthy , Date of Inspection: August 21, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D.- A. System Passes: a. ✓ I have not found any information which indicates that any of the'failure criteria rydescribed in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below: Comments: Conditionallyt asse B. Syem Ps:sz 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. , ...,r.f..�S: ;� s, i..� ..'.{ _13 r' FT�•A `k { ..�., -. 4�t -..^ Answer yes,no or not determined(Y,N,ND)in the F for the following statements. If"not determined",please eXplaln..g:I ,.Efs o, cy ° ��"',yi. rx'-x- #* 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: v 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' z obstruction is removed distribution box is leveled or replaced' ND explain: .._. -- ,The_system required-pumpmg_more_than 4 times a year due to broken or obstructed-pipe(s). The system will �..-,_._pass.inspection.if(witk approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: n 2 Page 3 of 11 OFFICIAL INSPECTION FORM _'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: t SS Crystal Lake Road---,--- , f Osterville, MA Owner: Arthur McCarthy Date of Inspection: August 21, 2001 -- - r ,4. 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- 12. A Sptein wilFfail unless the Board;of-H'ealth`(and PublWVater,Supplier,'if any)determines that the: system is functioning in a manner that protects the public health,safety and environment: ....'� f . ,j XA. �.� -r:;{; .31 .� t '�ti. }.F'�i-- {.,I j�- _ :� f.a E:.fft�{{`i.'�. i.. _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100:feetof a surface water supply or tributary to a surface water supply. - The system has aseptic 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 *T�is sJ te::-�p ss� fthe well water is,Per orn3ed at a OEP certified 1 boratory; fer o1.form bacteria and volatile organic compounds indicates that the well Js 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: s. 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) r• Property Address: SS Crystal Lake Road Osterville, AM Owner: Arthur McCarthy Date of Inspection: August 21, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level.in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below.invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground 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.l ofa public well:' A _ ✓ 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 thaw 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 System: ' To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gld• 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 _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS •SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �.v s PART B ,I:_ a_CHECKLIST Property Address: 55 Crystal Lake Road Osterville, MA Owner: Arthur McCarthy Date of Inspection: August 21, 2001 _ Check if the following have been done: You'must indicate`yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health _ _ ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility:or_dwellirig;inspeeted;for signs of sewage,back up? „(Owner,not home) Ki Was the:site inspected forsignsfof break out �-��t '-s <. far t. i,, ,si,'. <�_�..i�.'•z a -. .. .. : :a „Yi-:i ..k:. 'a f _... (; -li:. Were all system;components;excluding the:SAS,located on site 2 ✓ 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: 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)]. - .. . . _. . 5 n Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS .3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ;' SYSTEM.INFORMATION Property Address: 55 Crystal Lake Road • Osterville, AM Ott.• Owner: Arthur McCarthy T%- r, ;,r Date of Inspection: August 21, 2001 FLOW CONDITIONS• RESIDENTIAL . Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or,no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2000-130,000 Qals.; 1999 -215,000 Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: - Design flow(based on 310 CMR.15.203):.._- aud__ _.. Basis of design�flow(seats/pdrsons/sgftetc): ; "'a" �,;. }! +ti •, _.,'s,,.;- . Grease trap present(yes or no): Industrial waste holding tank present(yes or no) _ ... .._ _. _ r ;t' '._. ,,•,,: ` :;:' 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 on file-per treatment plant Was system pumped as part of the inspection(yes or no): No _ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any)_.. Innovative/Alternative technology. Attach a copy of the current operatiori and maintenance contract(to be obtained from system owner) Tight,Tank_ Attach a copy of the DEP approval OtHer(describe):'" ..if ^_, .'+,,,ci �.t i.{ . .,fu, ,a>; �.r, _�I rfl k'� J ,t �. -Approximate age of all components,date installed(ifknown)and source of information: _ September 20 1983-per as built card - Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 7 of 11 OFFICIAL`INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART C ;-'r"'SYSTEM'INFORMATION (continued) Property Address: SS Crystal Lake Road E.x,F ' #1�,?,� _t-1 _ ,� t!)A a sk << Osterville, MA Owner: Arthur McCarthy Date of Inspection: August 21, 2001 BUILDING SEWER(locate on site plan) a Depth below grade:. Materials of construction: _cast iron ✓ 40 PVC other(explain): Distance from private water supply.well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): , SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" 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) . ,;(aitach a.copy.of certificate) - cif , Dimensions: 1500 gal. . Sludge depth: 2„ :r: Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" ' Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related.to outlet invert,evidence of leakage,etc.): The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (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: x, y Distance from bottom of scum to bottom of outlet tee or baffle: x, . Date of last pumping: + .., a t r s Comments(on pumping recommendations,inlet outlet tee or baffle condition,structural integrity;liquid,"levels as related to outlet invert,evidence of leakage,etc.): ....__ .. ...... Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEMJNFORMATI.ON (continued) Property Address: SS Crystal Lake Road Osterville. MA �, � • Owner: Arthur McCarthy Date of Inspection: August 21, 2001 _ TIGHT or HOLDING TANK: None (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.): f r ri_ ;Ji 'FS ....;! .�`1 „.?T:a? .F,S,°°.. )C; t".`. .., • .. ":� «. ;f?.«FS}a!':" _'�'. r. t'1 't. , - , :::DISTRIBUTION:`°BOX. ,''✓ '(if present must be opened)(locate on site plan) -Depth of liquid.level above outlet invert: Even _ 4, °.k 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.): The D-box was level There were no signs of leakage or solids. The D-box was under a stone patio. PUMP CHAMBER: None (locate on site plan) a . 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.): 0 �.i.:-7..St�".� 41 �.»,�'i .... Fr. r (:It k'lc..i 8 r Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C T' SYSTEM INFORMATION (continued) Property Address: SS Crystal Lake Road_. . _ _ r:'_ �3 IV Osterville. MA -- y Owner: Arthur McCarthy __ "• ram: Date of Inspection: August 21, 2001 i M » SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why:. Type " leaching pits,number: 2-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: __.. overflow cesspool,number:. . - ____ ,_-._. .-Innovativelalternative system _Type/name.of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): One pit(93)had 3"of water on`tlie`•boffom.°}The scum"line was at:.the'same level. The pit:was'in new'condition}There were no signs of failure The bottom to grade was approximately 9'. The cover was 32"below grade. The other pit 04)was under a stone patio and was not dug up '} e CESSPOOLS: None (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: None (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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS {; 4 `SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION (continued) Property Address: 55 Crystal Lake Road Osterville, MA Owner: Arthur McCarthy Date of Inspection: August 21, 2001 , Map: 140 Parcel: 195 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. 3 - RA r, _-.�=�li,Y_y !3O ,. S't;_.��: =41 ;1 �l?}•vi :.i�.\� _c. t s r ��,.5� t•. S bra .-� f_` r, •' x r S 7 a •r ADL- G."I 3 S A 3- �- 83- `Iq A4 q 9 3 � l � s / r aa .. . y., - .. ..F. °s` .l «'#s:, r,. ..c r•.. #`'. .''.+i.„1tv „fir t�:., s::':,.i •. 10 Page 11 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C =` SYSTEM4i4F0RMATI6N (continued) Property Address: 55 Crystal Lake Road Osterville. MA _. . ;...... ......... Owner: Arthur McCarthy _ Date of Inspection: August 21, 2001 = SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic&water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS;database-explain: - You must describe how you established the high ground water elevation The bottom of the leach"pit to grade was approximately 9' Using the Barnstable topographic map and the Cape`Cod Commission water contours map the maps were showing approximately 30'+/-to groundwater at this site. . 4 . t This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,"written or implied, relating to the system, the inspection and/or this repor'. - z I aq A �/ol . 30. p Grov.►�w��'�� l-evL� j `Y 80 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS R DEPARTMENT OF ENVIRONMENTAL ]PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-WO WILLIAM F.WELD Governor TRUDY COXE Secretan ARGEO PAUL CELLUCCI DAYID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner JC PART A �l.CERTIFICATION Property Address: `� T lkOnd Address of Owner: co ,„ e Date of Inspection: 2 ��Py -� (`v/' (If different) a. m Name of Inspector: �J I`C LLJ �' Q I am a DEP ppr ved system ins ctor pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: C.e_7 (f, U.I (v m Mailing Address: w .Telephone Number: LU = o CP CERTIFICATION STATEMENT ry I certif y that I have personally inspected the sewage disposal system at this address and that the information repo rte b loweis true;accurate and complete as of the time of in pection. The inspection was performed based on my training and experience in the -ropery nction and ` maintenance of on-site sewa disposal systems. The system: I Passes I • 4 _ Conditionally Passes Needs Further E luation By a Local Approving Authority _ fails , Inspector's Signature: Dater The System Inspector shall submit a copy of this inspection report to the Approvin uthority,4ithin thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. • ;I INSPECTION SUMMARY: Check A, B, C, or D: �+ A] SYSTE ASSES: (' i I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not eva 'ated are indicated below; COMMENTS: /,2i�i►� ,L 0�9r!'! n r/��✓t � 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. Indicate es, no, or not.determined (Y, N, or%ND): Describe basis of determination'in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 0! 10 DEP on the World.Wide Web: http:/twww.magnet.state.ma.us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM , PA T A / �c CArntinued) /� Property Addr�`^_ Owner. Date of Inspection: �������� ; B SYSTEM COND14 NALLY AJ� SSES (continued) Sewage backup or breakout or high static water level observed in.the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Hei Ith). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced r The system r quired pumping more than four times a year due ato 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 CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER, HICH WILL PROTECT THE PUBLIC HEALTH AND 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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT T E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE E VIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OT ER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION (continued) t Property Address: • / / Owner: �- --a, Sr4 / Lo �� Date of Inspection: s D SYSTEM FAILS: *must indicate ei;!,er "Yes" or "No" as to each of the4ollowing: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted,to determine what will be necessary to correct th failure. Ys N Backup of sewage into facility or,system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or.clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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 Soil,Absorption System; cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analyst. If the well has been analyzed to be acceptable, attach copy.of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen: E) RGE YSTEM FAILS: Yo must Indicate either "Yes" or "No" as to each of the following: he,following criteria apply to large systems in addition to the criteria above: A he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one.or more of the fo)lowing conditions exist: Ye 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=1WPA) or a mapped Zone II of a public water supply well) Th own r or operator of any such system shall bring the system and,facility into full compliance with the groundwater treatment.progra.m req irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (reviaad 04/251/97) Page 3 of 10 fi' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l dyt ( � `r f/ l Owner: �!- e J /Q I Date of Inspection: Check if he following have been done: You must indicate either "Yes",or "No" as to each of the following: Y s No Pumping information was provided by the owner, occupant, or 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 volumes of water have not been introduced into 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 system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, 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 Soil`Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] i (revised 04/25/97) Page 4 of 10 i i" ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAT ON , Property Address: Owner: 7j Date of Inspection: _ FLOW CONDITIONS RESIDENTIAL- Design er©�.p.d./bedroom for S.A,S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): v'�d Laundry connected to system yes or no): ,% Seasonal use (yes or no): �fQQ - //7 G Water meter readings, if avails le (last two (2) year usage (gpd). Sump Pump (yes or no): a Last date of occupancy: Ct rzs jo7 COMMERCIAUINDUSTRIAL: Ty f establishment: Design gallons/day Grease trap pre es or no)_ Industrial Waste Holding resent:_(yes or no Non-sanitary waste discharged to t e stem: (yes or no)_ Water meter readings, if available: Last date of o�riubp) ancy: OTHER: (D Last d of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE O YSTEM . 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: �� Sewage odors detected when arriving at the site: (yes or no)h � (rrvisod 0{/2S/97) Page S of 10 •3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM NfORMATI ( ntinued) d Property Address: Owner: r .Cl/lj� Date of Inspection: BUILDING SEWER: (Loc a on site plan) Depth below e: Material of construc�i cast it _ 0 PVC_other(explain) Distance from pri water supply w uction line Diameter Co ents: (condition of joints, venting, evidence of leakag SEPTIC TANK: (locate on site plan) Depth below grader Material of constructs n: concrete metal Fiberglass Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: � � k Sludge depth:it — �i Ole, Distance from top, stud a toP�ttom of outlet tee orbaffle: Scum thickness: 1 � A 14 Distance from to o scum to top of outlet tee or baffle:Lr�/ T Distance from bottom of scum to bottom of outlet tee,or baffle: = How dimensions were determined: -IAe f)4 S(/B2 Comments: (recommendation for pumping, condition of inlet aj'd outlet tees or baffles, depth of liquid level in_celatio to outlet invert, structural integrity, evidence of leakage, etc.) /�!�'!' � - G SE TRAP: (locat n site plan) Depth belo rade: Material of cons ction: concrete metal 'Fiberglass PolyethyI other(explain) Dimensions: Scum thickness:- Distance from top of scum to t of outlet tee or le: Distance from bottom of scum to b om of t et tee or baffle: Date of last pumping: Comments: k . (recommendation fo umpina, condition of Inlet d outlet tees or baffles, depth o..f.liquid level in relation to outlet invert, structural integrity, evide of leakage, etc.) (revised 04/25/97) Pago 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6? ipel Owner: Date of Inspection: �/a sJ9s TIGHT OR HOLDING TANK: (Tank,must be pumped prior to, or at time, of,inspection). locate on site plan) Depth ow grade: Material o struction: concrete _metal Fiberglass _Polyethylene._other( explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in r ing order No Date of previous pumpin j Comments: (condition of t tee, condition of alarm and float switches, etc.) i . DISTRIBUTION BOX: k (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of.leakage into or out of box, etc.) j PUMP CHA (locate on site plan) Pumps in working order: (Yes o ) Alarms in working order (Yes or No) Comments: (note condition of amber, condition of pump appurtenances; etc.) ,J 7 x•Y (revised 04/25/97) Page 7 of 10 I t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I FOR TION (continued Property Address: lL{ 1kk � Owner: fw W. !� y Date of Inspection: !`'( SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) e If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number._ leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: omments: Irk to condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan Number and configurat n: Depth-top of liquid to in invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pum Vp art of inspection; ' Comments: (note condition of soil, sign/oydraulic failure, lev of ponding, condition of vegetation,etc.) PRIVY _ (locate on site an) Material of construction: Dimensions: Dep oYsolids; C ments: (note condition of soil, signs of hydraulic failure; level of ponding, condition vegetation, etc.) {revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ySr �YSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: r SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revised 04/25/97) Page 9 of 20 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTE.Nt INFORMATION (continued) tyo� 41 �p Property Address: Owner. Date of Inspection: ����• �� / Depth to Groundwater" 3Feg G o. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) De mine it from local conditions.. with local Board of health B Check FEMA Maps Check pumping records Check cal excavators, installers zzlulse USGS Data Describe in your own words how you established the'High Groundwater Elevation. (Must be completed) R . � a I Gov � (zavimad 04/25/97) Page 10 of 10 y Ai . CO lb k n L•O-C.A,T ION SIWAG E. PERMIT NO. VILLAGE INSTALLER'S NAME b ADDRESS Sp : off 7 S S',4 N U I L D E /RI OR OWNER R o DATE PERMIT ISSUED (9 3 DATE COMPLIANCE ISSUED ;: o t �� V'l 1 TOWN OF BARNSTABLE :. ss Cr�s�4l �✓a� SEWAGE # 3 -03 LGG~,A-7'I lv y$,LAGE 0- 1"CrV L ASSESSOR'S MAP & LOT INSTALLER'S,NAME&PHONE NO. ' SEPTIC TANK CAPACITY ' LrACHING FACILITY: (type) (size) ._�at1;�•, NO.OF BEDROOMS BUILDER OR OWNER r U� ✓�L A��l.. PERMITDATE: COMPLIANCE DATE: =q90 B3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply We11 and Leaching Facility (If any wells exist on site: f within 200 feet of leaching facility) Feet Edge of Wettand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)-- Feet {OcCI" �Orl Furnished by ' QnT o A;L- A3 - 33 Ay_ y8 .) Fxs.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /7�elo . ....................OF... r!�.'� %. -----..............................------ Appliration for Di-4pniitt1 Works Tonstrnrtinn rnmit Application is hereb made for a Permit to Construct (ij or Repair ( ) an Individual Sewage Disposal System at: 45 .......... .......... .. - Location-Address or Lot No. Owner Addy-ess a ---•-�-'.. :..... ®.'mil. .A�................................................... 4j i.1... .�......................---..................--- Installer Address Type of Building Size ...Sq. feet U Dwelling—No. of Bedrooms---�.a�'e........................Expansion Attic (��) Garbage Grinder (� Other—Type of Building pF'............... No. of persons........J�............... Showers (c.?) — Cafeteria ( ) a Other fixtures --------- ---------------- ` W Design Flow..11A.Y.`�.'.....v��..........gallons per person per day. Total daily flow....................y �.............gallons. WSeptic Tank—Liquid capacity/ gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width_. ............... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......�._..----- Diameter....... Depth below..inlet.-............. Total leaching area...Q .._sq. ft. Z Other Distribution box (/) Dosing tank ( ) Percolation Test Results Performed by..�'-9_.DTP."................................................. Date......'«. ........... aTest Pit No. 1......./."'.minutes per inch Depth of Test Pit._-.Ja?......... Depth to ground water... .®............. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................---. P4 ••--•••-............................................................................................--••-•••-•----••--.....--•-.......-•••-•......•-•-.---•- O Description of Soil............0--(Q--........ ."-?....'` .5 �� .............. -------------------------------.------------ x 0? ..` e� S�.w7 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 TITL 11 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. C/- Signed •- - . ...... .............. ,tom 3� J Date Application Approved By......... .... ( j�j .._... -------, ,) _,, Date Application Dis pi ov f or the f of ting r ons: -..-•................•-•----------------------------------.r� Date...._.. Permito------------------....................................... Issued...........................................----•....... Date �1 No................. 0 FEs.....-j...._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH s f .✓f .... - .............OF..- ��l.r./.,S .!9 B. ......................................... Apli iratioaa for Diipoii al Workii Tow3uurtion Prrutit Application is hereby made for a Permit to Construct (4.-j or Repair ( j an Individual Sewage Disposal System at: ......................................................... Location-Address or Lot No. .........M ta-�=.C.I n............. ............. ................................................... Owner Address ........................................... Installer Address Q Type of Building Size Lot_ /fir.. �!....Sq. feet U Dwelling— No. of Bedrooms-__!`Q:'...........................Expansion Attic Garbage Grinder (A19 pa,, Other—Type of Building A!).............. No. of persons........31........_______. Showers Cafeteria ( _ ) a' Other fixtures --___-.--"....................... Q -------------------.•••-------------------•---------- -•- --------•-------------.-------•--•-•••-••---....... W Design Flow..10Y.Y.=......'!Wf)-.......___gallons per person per day. Total daily flow.......................e!'YA............gallons. WSeptic Tank—Liquid capacity/!_gallons Length.........:...... Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...........__.......sq. ft. Seepage Pit No______ __________ Diameter........ ...... Depth below inlet... ........ Total leaching area... ..sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by... IC?.C'. .................................................. Date.....::d-/!_:. l�-"............ Test Pit No. 1-------l_.:'.minutes per inch Depth of Test Pit..../a.......... Depth to ground water---_-.<>............. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ ----------------------------------------------------------------------------••-......•-•-----•-••---......................................................... O Description of Soil.------..... "= -----••..:r.t 2.fT?---- -'<--------•------------------••---- 'rCti qQ_"/e......_..._�!e?"�----''.`'�` --------•-------•----.....---•--............................................................ U W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...........................>................................------------•-------------••----.......--•-•-.....--------------------------------•--•-----------------•-----------•---....-•-•--.....•••-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary 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. Signed.._�_�+4,^ !--cam r�__ G.�•_ `a:..................... �. .......... r !_..-----•--..._---- Date Application Approved By-----••. . ?!""; �-r �_Date Application Di pproved for the following reasons:------------------•--------•-------•-----••------...-----•----•-•-•••---•-•----- •.............. S7 .. J ,� ---------------------•-------•••�- ••... i -----� f �`���c:i:i-•-N;-- -:-----••--•-•-•-------------•---••----•-•---•------•---•-----...---_....--Date ._...------- Permit,,No------------------------•-----------------.......-------- IssuecL........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................O F....,�i�4!�/ ��7.. ?.:" ' ?......................................... d �h CIrr#if iratr of TompliFam THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1--) or Repaired ( ) by...................... z 2&-�----------------------------•-------•-----------------------•-•---------.... -------------------------------- Install I.—P at............................... r --- < . h has been:;installed in accordance with the r�isions of TITLE LB p 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--------g.--?- ...... dated................................................ THE ISSIJ NCE F THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE THAT THE SYSTEA+I WI F CTION SATISFACTORY. DATE... 2®-_. Inspector--._-_-. -- • _ -• •-----•..--•--------•--•-•-----•---•--••--...----•............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.....,'r. � ...... ��'' ✓E, .................OF...... ..�ir.'f.✓. T ..�.(-•--•---......................... FEE...... . �io�roottl orko �on,a�#� ion �eranit Permission is hereby granted '`% 9 - �..----••••--••••----•---•----••-•••-••-------•-•-........---•---•............. to Construct ( or Repair (�) an Individual Sewage Disposal System y Street as shown on the application for Disposal Works Construction Permit No..................... Dated----------------------A................... . J •---_' �,-._t.j...�, __ /....................... -.................... .......... /G/v� aard of Health DATE............................................ .. FORM 1255 A. M. SULKIN, INC.. BOSTON } I <•�I►JGLC-. FAM��`� - �.. BEOR�oM . No GA,czBAGE Ge, DE2 � .. I) p/a►Lam( F L O W _ 11,c3 = ' 6.P D �► !I „riEPT1G T!�►•�K = 4, ,x15C> -fa 6 &.P. C) Ae,�A o15Po5�L PIT u5E2 1000 (SAL-. �- IpP r j5►p�h/pLL AeC-.A. = 1�o S.� i d .• • 150 S.F X �.•5 - 3? 5 6.?� • F�oP 50TTOM AREA= �o <�'r II 5 5.F x 1. O 5 o G•P 2.z 0 9�-Q p 'T oT A 1- D 1`S I G N - +2 5 G.P D. X 2� -ToTA 1 L`( F w d4 P¢oP• (�5� . j PE2CoLATIoN RATE 1"IN ZMIN o�LE55 _ ` `Sf loo I •�'° •1�f 88 Of A� -V'VA ' ALANW. � JO ES '' ,'�fZ' 10 �l 2.. /�� L SZ•3 i /oq L I.`•i� BA.XTER v ?5100 • P1 .2s048 ?- - 99 •L - - - - 9j�0IS - O II <>TAIT H0L -Z IGG �C� TOP FNU = 100.0 'fE i � .fir, LAM q4L. INJ. i SvB�.�o�C.. 2 e� G � INJ. 9G-� Q c,6priG Z' (000 INS(• 9G-G TA►•1K i GAL. y� P I.>-5 I N V. INV. 9�� WITO MOD- 1'/3/�•�%L ..x'• 4 WASLAGD � ^ 67uNE �o , .at9i • � CEZTIFIGD PLoT PLAN PQ.UFIL.� LoC4-eloN O7T'Z\ll ZZ7 /2 t4 o. CA L E Ll w� 0 ><UAj l. 'p>zo ps e PLAN R E F 1✓2E N c- ' CESIT%F'Y THAT THE el. SNokYN µLO:soN COmFou%(5 Y41TN'TH S ►o�L►N � I �vU - AIo SET�GK � 6R uIR.EMEN7� F Tµ� �� OWN of ANC IS ? " LO>~PTE D W -7S ITNI 'T DATE $-Z' - BA (TGZe• NYE INC. LAu o 5 u 7W3 PLQN 15 Nam' 4n5r o p►d AN OSTEQVILL� - ASS• i 'IIN5TRuMENT Su2VEY � -TNE D1:r,'5 5 Suou �PP�ICP.� r I No DE 'U5I5DT0 pETEFZ/^I►.lE �.o"i" L INE•5 _p,'x. 1 /��