Loading...
HomeMy WebLinkAbout0153 EVANS STREET - Health 153 Evans Street;-Oster;Mle i " i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is Osterville MA 02655 10/30/13 required for every ' page. City(rown_ State Zip Code Date of Inspection " r Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important:When filling out forms A. General Information ' on the computer, use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay use the return Name of Inspector key. Shay Environmental Services, Inc. Company Name 185 Ashumet Road Company Address ' 1 r Mashpee MA 02649 Cityrrown State Zip Code 508-539-7966 3080 Telephone Number License Number- B. Certification ` I certify that I have personally inspected the sewage disposal system at this address and that the =F 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,9f once sewage disposal systems: I am a DEP approved system inspector pursuant totection .340 I„,V Title 5(310 CMR 15.000).The system: ::D ' 0 Passes ❑ Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local-Approving Authority -� ' 10/31/13. Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 135 Evans Street,Osterville,MA doc-03/08 Title 5 Official InspectIFubsurface Sewage Disposal System-Page 1 of 15 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 153 Evans Street 4 M - Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA 02655 10/30/13 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) . Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: x ❑x 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ' Comments: Leach Pit has No Liquid. 3:5' Stainline noted, 2.5'effective depth available in Leach Pit. 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 r..mmnlivinra inriiratinn that thin tank is lace than gn vaars nlri is availahla 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 135 Evans Street,Osterville;MA doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 r e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA 02655 10/30/13 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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: El 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. 135 Evans Street,Osterville,MA doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 s , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 153 Evans Street Property Address Michael Linnane Owner Owner's Name . information is required for every Osterville MA 02655 10/30/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No - Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool n i El 0 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 ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ N 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 135 Evans Street,Osterville,MA doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA 02655 10/30/13 page. City/Town State Zip Code. Date of Inspection. 9 B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No El ❑x Any portion of a cesspool or privy is within &Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ M The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ❑x The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. ; For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface'drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area 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. 135 Evans Street,Osterville,MA doc•03(08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is Osterville MA 02655 10/30/13 required for every _ page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health El ❑ 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? ❑x El Have large volumes of water been introduced to the system recently or as part of this inspection? El available as built plans of the system obtained and examined? (If they were.not available note as N/A) N ❑ Was the facility or dwelling inspected for signs of sewage back up?. N ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? ❑x ❑ 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? S • - The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑x ❑ Existing information. For example, a plan at the Board of Health. N ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 135 Evans Street,Osterville,MA doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA 02655 10/30/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: i 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: ,. 0 Does residence have a garbage grinder? ❑ 'Yes ❑x No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑x No Laundry system inspected? 4 ❑ Yes ❑x No Seasonal use? M Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)):, Sump pump? R ❑ Yes Z No Last date of occupancy: August 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design'flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.):' Grease trap present? r ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 135 Evans Street,Osterville,MAdoc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information required for every Osterville MA 02655 10/30/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health v Was system pumped as part of the inspection? ❑ Yes 0 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 O Overflow cesspool ❑ Privy r ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the'DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1983-per asbuilt card Were sewage odors detected when arriving at the site? ❑ Yes ❑x No 135 Evans Street,Osterville;MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 1 - I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA 02655 10/30/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ❑x 40 PVC ❑ other(explain): } Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank(locate on site plan): . Depth below grade: 1.5 feet Material of construction: N concrete ❑ metal ❑fiberglass ❑ polyethylene ❑'other(explain) If tank is metal, list age:• years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'x 8' - 1000 gallon s Sludge depth: 611. Distance from top of sludge to bottom of outlet tee or baffle . 26" Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured 135 Evans Street,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 NN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA 02655 10/30/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal` ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ` Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 135 Evans Street,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 ' h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA 02655 10/30/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont,) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm-present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present 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.):' One outlet present to leach pit. Dbox in fair condition. No evidence of solids carryover noted. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 135 Evans Street,Osterville,MAdoc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 + I Commonwealth of Massachusetts ,,. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T (�N 153 Evans Street Property Address . Michael Linnane J Owner Owner's Name information is Osterville MA 02655 10/30/13 required for every . page. City/Town State _ Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): ..- If SAS not located, explain why: Type: leaching pits number: "I -6'x 6'with 1' stone ❑ 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.): Leach Pit has No Liquid. 3.5' Stainline noted, 2.5'effective depth available in Leach Pit. 135 Evans Street,Osterville,Mikdoc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 1 ` A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is Osterville MA 02655 10/30/13 required for every page. Cityrrown State Zip Code Date of Inspection r D. System Information (cont.) 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 Y f Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes © No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids : " 9 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 135 Evans Street,Osterville,M/ldoc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SVB'a 153 Evans Street Property Address Michael Linnane Owner Owner's Name ' information is required for every Osterville MA 02655 10/30/13 page. City/Town State Zip Code Date of Inspection Cards age i` 1 �M LOCAt40" s t W 'i6E BEM#AtT � It VIILAaE r ` 1,NjjTktLI*1 NAME A AQOREfS • UII.QEN 011 OWNER �� � p ��yr, � r HATE PERMIT -1 S S to f-01, BATE COM/1 IANC;E JSSUEQ fo" }} N IV- rg. e, POO 135 Evans Street,Osterville,NIA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 L - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 153 Evans Street Property Address Michael Linnane Owner Owner's Name information is required for every Osterville MA' 02655 10/30/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: E' ❑x Check Slope j Surface water ❑x Check cellar ❑ Shallow wells Estimated depth to high ground water: fee t 16 feet . Please indicate all methods used to determine the high ground water,elevation:' Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150.,feet of SAS) ❑ Checked with local Board of Health -.explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high groundwater elevation:., Inspector has performed engineering design and perc test on this street. 135 Evans Street,Osterville,MA doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts ExecutNe Office of Environmental Affairs DeIs a rtment of RECEe!! ® Environmental Protection OCT ? a 1996 William F.WeldGammor T►udy Coxe AAry eoeo Paul Ceiluccl TOWN O T, DCP1s«�«.ry �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION Property Address: , �'��'t'�O S oz 4i _& Address of owner. Date of Inspection: 6 O- /U �t (If different) Name of Inspector. Mar- in.v Company Name,Address and Telephone Number. S� �'►�carzr'i.t..� Sr�.pfy CcS S� -f- Rom' 7 CERTIFICATI 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: //� -A- Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within 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. INSPECTION SUMMARY: Check A.B, C,or D: A] SYS� A I ASSES: V 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 evaluated are indicated below. B1 SYSTEM CONDITIONALLY PASSES: One or more system components used to be repL►oed or repaired. The system,upon completion of the replacement or repair,passes Win• Indicate yes,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,cracked,structurally unsound,shows substantial infiltration or ex8ltration,.or tank failure is The system will pass inspection if the existing septic tank is replaced with a lonforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Wrote►Street • Boston,Massachusetts 02108 • FAX(611)356-1049 • Telephone(611)292•Sp0 Pe.I don Rac W Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: " Owner. Date of Inspection: 1.t � B SYSTEM;CONDI O] 'PASSES(cgntmued) Sewage p or breakout or high static water level obaerval the distribution box is due to broken or obstructed pipe(s) or due to a ken,settled or uneven distribution box. The stem will pass inspection if(with approval of the Board of Health): broken pipe(&)are replaced obstruction is removed distribution box is leve or replaced q The system required pum ' more than four ' es a year due to broken or obstructed pipe(s). The system will pass inspection if(with approv f the Board of alth): ken pipe(s replaced o ruction ' removed C) FURTHER EVALUATION IS REQUIRED TH BOARD OF HEALTH: Conditions exist which require furth evaluation by Board of Health in order to determine if the system is failing to protect the public health,safety and the en ' nment. 1) SYSTEM WILL PASS S BOARD OF HEALTH D INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL OTECT THE PUBLIC HEAL. AND SAFETY AND THE ENVIRONMENT: Cesspool or p is within 50 feet of a surface water Cesspool or rivy is within 50 feet of a bordering vegetated d or a salt marsh. 2) SYSTEM WILL ALL UNLESS THE BOARD OF HEALTH(AND P LIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES T THE SYSTEM 1S FUNCTIONING IN A THAT PROTECT THE PUBLIC HEALTH AND SAFETY THE ENVIRONMENT: e system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a ce water supply. _, The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and 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 leas than 5 ppm. 8) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM II PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: D) SYSTEM FAILS: I have determined that the in violates one or more of the following failure criteria as de ' in 310 CMR 15.303. The basis for this determination is identifi low. The Board of Health should be contacted to determin what will be necessary to correct the failure. Backup of sewage into fe ' or system component due to an overloaded ogged SAS or cesspool. Discharge or ponding of eliluen to the surface of the ground or surfs waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution above outlet invert a to an overloaded or clogged SAS or cesspool. i _ Liquid depth in cesspool is less than 6" low invert or ailable volume is less than 1/2 day flow. Required pumping more than 4 times in a last NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption System, 1 or privy is below the high groundwater elevation. Any portion of a cesspool or privy is hire 100 f t of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or p ' within a Zone I a public well. Any portion of a cesspool or rivy is within 50 feet of a 'vate water supply well. Any portion of a cess or privy is less than 100 feet but ter than 50 feet from a private water supply well with no acceptable water analysis. If the well has been analyz to be acceptable,attach copy of well water analysis for coliform bacteria, tile organic compounds,ammonia nitrogen d nitrate nitrogen. E)LARGE SYSTEM FAILS: The following cri ria apply to large systems in addition to the criteria above: The system rves a facility with a design flow of 10,000 gpd or greater(Large System) d the system is a significant threat to public health and ety and the environment because one or more of the following conditions erci�t 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 lI of a public water supply well) The owner or operator of any such system shall bring the system and facility into lull compliance with the groundwater treatment program requirements of 314 CNR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. ". (revised 1-1/03/95) S � y r...+.s x+.^.e...-+•s^.++p�w.1.-......k.-...-.,.,...»-.. -r- �,...,.--..._..+• «, ..' s: - - r =.s- ♦ a-r ' SUASURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: to --( O— Chsck if the following have been done: `f Pumpling information was requested of the owner,occupant,and Board of Health. LeWone 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. 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 was inspected for signs of breakout. !„system components,excluding the Soil Absorption System,have been located on the site. C,,- he septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of bates 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 existing information or approximated by non-intrusive methods. e facility owner(and occupants;if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. r (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5 6L'. � S�- Owner. - Date of Inspection: to -- FLOW CONDITIONS RESIDENTIAL• Design flow: V gallons Number of badrooms:_11 Number of current residents— Garbage grinder(yes or no):_&,�' laundry connected to system(yes or no)� Seasonal use(yes or no):� Water meter readings, if available: last date of occupancy: ` COMMERCIAL/INDUSTRIAL Type of establishment: Design flow:--gallons/day Grease trap preagn't^(q or no)_ Industrial Waste Bolding resent: (yea or no)_ Non•sanitary waste discharged to 5 system: (yea or not_ Water meter readings,if available: Lest date of occupancy: OTHER:(Deacr Last date paary: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yea or no)_tV,> If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM y�eptic tank/distribution bos/soil absorption system Single cesspool Overnow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: z9>i— �_ N l!l Sawage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 77 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: SEPTIC TANK_L—� (locate on site plan) A Depth below grade:_ d - Material of construction:�crete_metal_FRP other(explain) Z [► SL y i[� sc Dimensions: Sludge depth: — S 30 to Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: n _ /. Distance from top of scum to top of outlet tee or baffle: s Distance from bottom of scum to bottom of outlet tee or baffle: /Z Comments: (recommendation for pumping, condition of inlet and outlet tees or es,depth of 'qui level in relation to let invert,structural fate 'ty, evidence of leakap, .) o GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:_con metal_FRP—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 outle or baffle: - Comments: _ (recommendation for pum ' ,condition of inlet and outlet tees or baffles,depth o uid level in relation to outlet invert,structural integrity, evidence of leakage ) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address- '6 Owner. Date of Inspection: q TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of' tee, condition of alarm and float switches, etc.) r DISTRIBUTION BOX_.V (locate on site plan) Depth of liquid level above outlet invert: Comments: _ (note if level and distribution is equal, evidence of solids cagyover,evidence of leakage into or out of box,etc.) .dIJ62n4 D lrrv� PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,con ' ' of pumps and appurtenances,e (revised 11/03/95) 7 . 1 S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM { PART C SYSTEM INFORMATION(continued) Property Address: r �; Owner: r Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):v (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: iType. leaching pile, number:_ leaching chambers,number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note njktion of soil, igns of hydra 'c failure, level of ponding, condition of vegetation,etc.) c CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top o ` 'quid to inlet invert: Depth of solids er: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pum part o ion) Comments(n dition of soil, 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 gas of hydraulic failure,level of po condition of vegetation,etc.) (revised 11/03/95) 8 f . N FORM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION O PART C SYSTEM INFORMATION (continued) Property.Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks.or benchmarks locate all wells within 100' e,� �Z�"Or 0- 13 _ C• = 17 a DEPTH TO GROUNDWATER Depth to groundwater._,L _feet h rminati or approximation: :a �. (revised 0/35/95) 9 a` f.- a ` + �y � �'.ks �;. L 1 t - A.S S i S�� -�' ,. Y�� '.+� } :f,.•hL�"�3�4�"4M1'b S�+'X'�' " -�. Y J �.c� � 't 0'� I A r No..B j- -G �1 / .... ,1► Fxs.. THE COMMONWEALTH OF MASSACHUSETTS SOAR® OF HEALTH ...._-.-..."-""""......."""................O F......-.........:...-....-.--.-._.........--.......-......--------------.....-......._.__. - , pphratinn for Di-gVus al Works Tonstrnrtinn Verntit Application is hereby made for a Permit to Construct ( ) or Repair (man Individual Sewage Disposal System at: ........../ll:.�3.........Lv eel:_ .......cc�7__" e-llC -•--•----•------- 7...... - Location-Address - or Lot No. ............................................................. ........•. -------------......................._...-•---- �wner --•Address �L._ C!9.�J... ---•-••--••------------------- -_-__--•---____________-____-__-----•-•---- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building __ No. of persons__.._________________________ Showers — Cafeteria a' Other fixtures .................................................. ............. -••-------•-----------------•--------------____------_-•-.... --------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................ 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........................................................................... Date........................................ ,4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fTo Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ ------------------------ •....................._..........................-.......•----------- -----....._.. ------ 0 Description of Soil.....................................................................................................-•------------------------------------------------...•-••...••-••- x .........................--------------•-....................................................................... •-----•---:..•-•'•-•---------------•-------------------_.........: V Nature of Repairs or Alterations—Answer when applicabl4dw Gp__._.'a ___________ g_u . _- 1 ----------------------------•--•------------------------•--•------------------------.....•---_••-•••-••-•--•--•----•---•-•••----••-••---•--------..----•-•--••-•-••-•---•-----------•---••---•--•••---•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T?':I Z' y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until.a Certificate of Compliance has been sued by the boar of health. Signed...... . .......................... ...........•-__•-••--•---•--••••••....-• •.... Application Approved .---' ---........................................... ��r�Zte 3-•---____ Application Disapproved for the following reasons---------------••-•----••----•-----------------------•-------------------------------••-•---•----•-••••••--.._.._ Date PermitNo......................................................... Issued,_:,................................................... Date ' Fmm ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ....................OF..................................... ................................................ Appliratiou for Disposal Works Tonstrurtion "rrmit Application is hereby made for a Permit to Construct or Repair (�an Individual Sewage Disposal System at: ........... ....... .................02r.. .................................... ..................................... Location-Address or Lot No. je 4 ....I.V......... ----------------------------------------------- .................................................................................................. P-ner Address ew...... -4-7-. ......................... .................................................................................................. Installer Address U Type of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic Garbage Grinder ( 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( 04 Other fixtures .................................................................:.................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. . 1:4 Septic Tank—Liquid capacity............gallons Length................ Width__............._ Diameter._._.__..._..._. Depth................ Disposal Trench—No..................... Width......_......__..... Total Length__.................. Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.._......._..__..... Depth below inlet.................._. Total leaching area..................sq. f t. Z Other Distribution box Dosing tank t-4 Percolation Test Results Performed by........................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.._.__....._...._... Depth to ground water...................___.. Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............................................................................................................................................................. 0 Description of Soil......................................................................................................................................................................... W ................................................................................................... ------------------------------------------------------------------------------------------------------ ......................................................................................7-------------------/ . ..................................................................I.........<4--vt. ......... e . U Nature of Repairs or Alterations—Answer when applicable&W"Z?----- ............ C_ ........................................................7......................... .................................................................................................................... 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,J, sued by the boar of health. .. ..................... .......................................... ..... Dat, Application Approved By.__',, ....... ....... - _ ------------------------------------------- ------- ......---- Date Application Disapproved for the following reasons:................................................................................................................ . .............................................................m............................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date THE-COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Toutpliattrr THIS IS TO CERTIFY hat the Individual Sewage Disposal System constructed or Repaired (4-T .......... by....... --------------------------------------------------------------------------------------------------------- J. ....... ........ - Installer at ................... ................................................................... ..... o 577. . 7 has been installed in accordance with the provisions of TI I-LE S f The State Sanitary Code as described in the .application for Disposal Works Construction Permit No._,:? ........ dated................................................. THE ISSUANCE 0 F THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARANTEE THAT THE SYSTEM WILL/f-UNOTION SATISFACTORY. BE CONS UED DATE........ .. .. .. ..................................................... Inspector---- ............. ............................................................... THE COMMONWEALTH OF IM11AS USETTS BOARD OF H TH ...... ......................OF..-.................................... ................. 0, ......N FEE........................ Disposal Works T-5onstrurtiott prrutit Permissionis hereby granted.....................f........ ------------ ----------------------*------------------------------- to Construct �, ,)) or Repair (6, "an Individual Sewage Disposal System '_-71........... ....... ......................... ---------------------------------------------------------------------------------------- Street asshown on the application for Disposal Works Construction Permit No__________ _________ Dated_......___._........_..................... 0_f ............................................... f �e oard 'o Health DATE.............. ms .................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS LOCATION SEWAGE PERMIT NO. VILLAGE . 145 "IN TA LLER'S NAME ADDRESS v d UILOE R OR OWNER DATE PERMIT ISSUED �� � 3 DATE COMPLIANCE ISSUED �� �3 ' _ � �oyr 3 d � � o � �� rr' S�'oo No.. �D . THE COMMONWEALTH OF MASSACHUSETTS . 9 BOARD OF HEALTH ....... oF.. ........ . --- _I Appliration -fox BiBpviiat Workii Cn>witrurtton Prrmit Application is hereby made for a Permit to Construct (k-1 or Repair ( } an Individual Sewage Disposal 'J System 't v� 'r�". /�iz ---------------------...--G- --------....`------..................------------........ Location-Address or Lot�o. o� ' � � �' ;ref 7". �, � Owner ! Address ak_-Jz... — ....... .......•.... ----- Installer Address dType of Building Size Lot....1 ao u--------Sq. feet Dwelling—No. of Bedrooms....-------s. ---- -------------Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building .__.. .---�� .�. No. of persons---------------------------- Showers ( ) — Cafeteria ( ) �4 d Other fixtures ......'Z--- ?lq6 W Design Flow............................................gallons per person per day. Total daily flow---------------------------------------.....gallons. WSeptic Tank—Liquid capacity-/go-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. it. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- ----------------------------------------------------------------- Date-------------------------------------... a Test Pit No. 1................minutes per inch Depth of "Pest Pit.........---.------- Depth to ground water.................-..-..- rXq Test Pit No. 2................minutes per inch Depth of Test Pit...---..-.--..-----. Depth to ground water....................... 1 ODescription of Soil..................................................................=--------------------------------- :--------------------------------------------- x U W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----. UNature of Repairs or Alterations—Answer when applicable..........................................................,...-......----------------------.... ----------------------------------------------------------------------- -------------------•------------------------------------------------------------------------------------------------------- Agreement: r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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. gned. p------------•----------------------•-- - Date /J ApplicationApproved By•---•--.. .... . . ------ --•--- •-•--•-----••-------------------- ....ref_......---------....... ------------------•---•-•-•--••-•-•-•----••-•--------------......----...................Date---.....--- . Application Disapproved for the following reasons:.. - ----------------------------------------------------------------------------------------------------•--------------------------------...-----------------•------....----------------------------- Date PermitNo......................................................... Issued........................................................ Date No......°` v Flzs ..... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .a. )'I----------------0F.........../��. fu�1��- Appliration for lh ipiittl Works Tonotrurtion Vrrmit Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal System at: . s , . -----------•----------------------------------------------•-------•--------------- ----=- ... ....................................................-•........................................... 1. Location-Address or Lot No. �l' �� r 4 �-/ .! r ............ 16141 ...f�, Owner - Address Installer Address Q Type of Building Size Lot.....f-�;.... .......Sq. feet aDwelling—No. of Bedrooms_-__---........::....... _._--Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ---- -.. __ No. of persons___________________________ Showers ( ) — Cafeteria ( ) dOther fixtures ------ ----- ------------------------------------------------------------------------------------------------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow----------------------------------------.---gallons. WSeptic Tank—Liquid capacity-/4! .-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-_-_--_.-______-Sol. It. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------------------...................................................__ Date-_.--------------------.-_-------------. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water_--______-__-___--___--. Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.__-_______________---- -----------------------------------------------------••---•--------•----•••--..........••-•-..••----......................................................... 0 Description of Soil..................................................................--------•--•-----------------------------------------•--------•-----_-_-------_-------------------- 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 Article XI 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. .. Application Approved B �� ��✓/ Date Date Application Disapproved for the following reasons_---------------------------------------___...................................................................... Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH .� ��� ............OF........ .. Sri z . ... ....................... Trrtif irate of TIMphattrei THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4,-�'or Repairedby ( ) ----•••. •-•••---•----•-•----•--••-•--•......-..-• ...... f-•-----•--•---------- I aller has been installed in accordance with the provisions of,rticle XI of The State Sa rtary -7Code as described in the application for Disposal Works Construction Permit .-..�.-/ ________________ dated'- - ...7-_S_:___------------ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM Wl jj,FUN 41ON SATISFACTORY. DATE--- ..............-- Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS ��f BOARD �OF HEALTH .... ,�r.............OF. . . .. ..(�..�_ ........................ rk,a Tomitrurtion Prrmit gPermission is herebyranted-- 7 ---__.--- `...=...................................................................................................... to Construo;r(f) o/r Rep '� ( ) an Indivj'dlu�, age-.,Disposal rystem at No.=-. .-<�( =: •....•.- `fir IG --------------•••--•-- f Street as shown on the application for Disposal Works Construction Permit No..................... Dated..>-f ........... ---------------------------------------------------•---•----.•----•------.........••-•••.--.•-•-••..... Board of Health DATE.-- --------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Gs, J s 4 f Y b i Diu , •QwY. j GAS t N RIC14 NAR[) y Ak- $ Na 2 �° SCAB E ,, ,z0 2Ei-ae F---N C - L.AQr-) C-ooi?r P(,AQ I C e C"'t Pv r144r TV4 a r-oo-,j0 a rl ok? r3 A XTT---Z e,,, LJVr= me �GCm+Srt +2 1..AQ r) SV WP-Yf 2S ©►J ��#$ (�t./a tJ 1 S l.0 GA r*© MASS OW TI4C 6,(ZOOO-1iZ) a AS ShyOwN HL%&j?Gotj IDATG IZE6 IITEkGrj LA WC) t vrz Ve:joe_ PET t T tC)Qr-- 1