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HomeMy WebLinkAbout0054 EBENEZER ROAD - Health 54 EBENEZERc;' v1 - 4 LOCATION _ u SEWAGE PERMIT NO V I L L A G i _ I N S T A LL R'S NAME R ADDRESS B U I L D E R OR OWNER c DATE PERMIT ISSUED 72� DAT E COMPLIANCE ISSUED 3 2E"h2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the I computer, r,use 1. Inspector: only the tab key to move your Darrell Stone cursor-do not Name of Inspector use the return key. Cape Cod Septic Inspection Company Name !� PO Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification s I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection ... wa :performed based on my training and experience in the proper function and maintenance of on site se,age disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of E c� Title 5(310 CMR 15.000). The system: :❑ Passe§ ® Conditionally Passes ❑ Fails M A1nspr'sSidna_tu_rq urther Evaluation byocal Approving Authority 4w - C-4 3-16-12 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. pp p� � . q f t5ins•11110 Title 5 O*Inspe-cnubsurface Sewage Disposal System-Pagel 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for every page. City/Town 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ® ND (Explain below): The septic tank was found to be leaking and requires resealing or replacement. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval.of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 R t5ins-11110 F Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 ❑ ® 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® 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 ❑ ❑ 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. t5ins•11/10 - Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 r ' Commonwealth of Massachusetts . Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ebenezar Rd. Marston Mills, MA M Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for State Zip Code Date of Inspection every page. Citylrown 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 ❑ ® 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 i i 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 3 Bedroom residential dwelling 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 68.49 GPD 9 ( Y 9 (gp ))� Detail: 2011 -0 gallons 2010-50,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 10-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ 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: t5ins•11/1D Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 x ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® 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 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): t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999 Per BoH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 19" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 13" feet Material of construction: ® 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: 1000 gallon 101, Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 6 Distance from top of scum to top of outlet tee or baffle @ 27„ Distance from bottom of scum to bottom of outlet tee or baffle _3„ How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was found to be leaking SCH 40 outlet tee Recommended tank to be pumped Recommended maintenance pumping every-23 years 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owners Name information is required for Marston Mills, MA 02648 3-14-12 every 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) must be opened) locate on site Ian): ' ribution Box if resent ) ( p Dist ( p p 0„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Grade to box 23" Normal liquid level No sign of leakage Scum (removed) 1 Outlet OK condition No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'q ,M 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): 4 Infiltrators with 4' stone Grade to infiltrator 46" Bottom 60" Inspection port 4" Dry No sign of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan).- Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 . Yy Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate Where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 Q A B 1 2 - 2 3 - 3 -Z 4 2 53 11 - 5 6 t5ins-11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Ebenezar Rd. Marston Mills, MA Property Address Steve Leblanc Owner Owner's Name information is Marston Mills, MA 02648 3-14-12 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells >5' Estimated depth to high ground water: 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: GIS.elevations on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Elevations from GIS certification report dated 8-22-1999 Top of Grade ELV. 44.3 Bottom of SAS ELV. 39.3 GW ELV. 15.0 Adjustment 3.7' Separation >5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "M 54 Ebenezar Rd. Marston Mills MA Property Address Steve Leblanc Owner Owner's Name information is required for Marston Mills, MA 02648 3-14-12 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No._.a 0 a Fee too. - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN,OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for Migpogal 6p9tem Con5tructton Verna Application for a Permit to Construct bk Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. E:1W[.GK-�� Owner's Name,Address,and Tel.No. Assessor'sMap/parcel t� 3— 0 j l `` 5 gwL �((; Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Q(�l►- >a '��fit=+�, Type of Building: i � Dwelling No.of Bedrooms N Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank kowbAla.013 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ?J1 SML 10DO 6NQ LW S2Pg1 -V - Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued bjs Boa of Healt . Signed �' Date Application Approved by M. G Date � Application Disapproved by: Date for the following reasons Permit No. {) Date Issued , Fee 1 �� f THE COMM ONW ALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOM ,OF BARNSTABLE,�MASSACHUSETTS N Yes Zipprication for Migogal �&pgtem ConsStruction Permit Application for a Permit to Construct(A. Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 54 C-W45Z M- a 0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a 1 Li � 1�c�� �� MA2S� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 'v j Lot Size — sq.ft. Garbage Grinder ( ) Other Type of Building No.of Person Showers Cafeteria YP g ( ) ( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank k ow bAL-LOB Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) &'\LL4>,3 `QV'X "C 1wC- t Date last.inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by.-this Board of Health. Signed qJ �. 4�' 1f Date Application Approved by rn G�G/�/L�, �,(t Date 3 Application Disapproved by: Date for the following reasons Permit No. V �'' p Date Issued " ————— ———————————————————————————_————————— THE COMMONWEALTH OF MASSACHUSETTS t ,'0, BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed O Repaired ( ) Upgraded ( ) Abandoned( )by at '::'4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer LAa H Ayz'n cJ Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be Spristrued as a guarantee that the system will�functio. 'add igned. Date /�! Inspector ! 3 a -------- No. �O� ' CJ U 3 Fee /00 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS MtgpozaY.*pgtem Congtruction Permit Permission is hereby granted to Construct Repair ( ) Upgrade ( ) Abandon ( ) System located at S4 M 0,2 ST-A M x s 1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date L) Approved by ! V 41�- G 16&jit / l ' Q¢THE Tpk y�P Town of Barost,,lble Baxxsrae[.E, Board of Health �$ MASS. a • 200 N(ain Street, Hyannis MA 02601 � �639. ,00 Al Susan G.Rask,R.S. Wayne Miller,bf_D. Fax:(508)790-63404 Office: 86 * Sumner Kaufinan'lvf.Sp.H. TEMPORARY OUTDOOR FOOD VENDING'REQUIREMENTS August 27, 1991, Amended May 2,2002 (due to fee increases and training requirements) Applicants who wish to serve free samples of food or sell any food at a fixed location fora period of time of not more than four(4) consecutive days in conjunction with a single event or celebration shall apply for a temporary p rary food permit from the Board of Health. Applicants who request a permit to serve or sell..food from an outdoor booth, table,or cart for more than four(4) consecutive days will not be approved. Also, applicants who request to operate a temporary booth,table or cart which would not be operating in conjunction with a single event or celebration will not be approved. Each special event or celebration must be pre approved by the Board of Health at a public meeting. . *Fee"The fee is$35:00 per cart table, booth for profit and non-profit organizations. Organizations selling the food in order to donate . the funds to charity will be' charged a fee,of$5.00. Applicants who-wish to sell or serve potentially hazardous foods shall demonstrate compliance with the following criteria. A. ra Potentially Hazardous Foods-.Only.those:potentially hazardous.foods requiring limited preparation, such as hamburgers;and frankfurters that only require.seasoning and cooking shall beprepared and served. ..The hazardous foods;including pastries.filled_with cre preparation and service of other otenhall am or's. the 'c P yn h cream,custards and similar'Products, and salads... y or sandwiches containing meat,poultry, eggs, or fish is prohibited(copied from Pro Code for Food Establishments). vision 105 CMR 590.030 of the State Sanitary The prohibition does not apply to any potentially hazardous food that. has been pre pared and ng the requirements �P P acka ed of the State P . under co Sant g ndit" f Code F _ lops mee • Sanitary or Food Establishments,is.packaged in individual servings,is'stored at a temperature of 41 degrees F, or below, or at a temperature of 140.degrees F.or above in facilities meeting the requirements of the State Sanitary Code 105 CiVIR 590.004, 590.006.and 590 007 and is served directly in the unopened container in which it was acka *ed: R.Sinks/Gloves—.Depending upon the,length.of-time of the event and the types offood proposed to be prepared and served, the).irector.of Public Health may require handwashing.sinks at the site..7f there are no hand wash sinks available,potentially hazardous foods-should not be appxoved.for:preparation at events which occur for extended periods oftirne(greater than fow.hours).. During those d a sufficient fici-events which oGegr for'shorter time-periods, the applicant shall provide,_at a mijj muw,'MOist. sanitizing,"hand-wipes"and a sufficientnumber ofgloves to be worn by all food handlers all times food is prepared and served. C. Tongs/Disposable Napkins—for re arinQ ' - P P o and serving unwrapped foods(without using bare glands). D. Refrigera tion/Cooler—Electronic refrigerator or coolers with ice p degrees F. acks and ice to keep potentially hazardous foods below 41 E. Thermometers(Stem-type)for testing the internal temperature ofpotenti"ally hazardous foods. F. Refuse Container—for the disposal of trash and garbage' G. Sneeze Guards—for the protection of unwrapped foods from the public and patrons during re p paratlon and serving. H. COvers/Plastic'Trapping—ofsome sort to keep unwrapped foods covered during storage or display, Z. Trained and Certified Person in Charge/Food Sanitation Training- The applicant must submit evidence of a trained and certified Person in charge(e.g.Servsafe or equivalent)who must be present during the duration of the event. 'ER ORDER OF THE BOARD OF STEALTH J 'usan G.,Ttask,P.S., Chairman yayne.Miller,M.D, - �rnner Kaufman,M.S.P.H. TOWN OF BA.RNSTABLE LOCATION `/ _ '7 SEWAGE # *� VILLAGE S ASSESSOR'S MAP & LO-11AF 3�"�.�1 INSTALLS 'S NAME&PHONE NO. AL 6q WZ SEPTIC TANK CAPACITY LEACHING FACILITY: (tyre) �.1LLl _ 7Q i� (size) JCzz NO.OF BEDROOMS 3 p OR OWNERi: 2 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility '(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ' } 1 43 1,33 No. / Fee J v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Dtgool &pztem Construction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System Oi;Wdividual Components Location Address or Lot No.✓ N C­r_Qvl� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ,r 4 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 o gallons per day. Calculated daily flow t�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. << Cc "G��iv c 0.1 Description of Soil i/kA/^1 Nature of Repairs or Alterations(Answer when applicable) l (�t I✓— d ✓ Lf its f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the prov' ' le 5 o�thhe vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has ssued by this C Signed Date Application Approved by Date Z ` Application Disapproved for the following reasons Permit No. Date Issued Z 9 ,.....�- No. / Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 'Ye 01pprication for Migpozar *p.5tem Construction Permit�" L Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System 44adividual Components i^ Location Address or L,'ot No. ti t••Z�� € Owner's Name,Address and Tel.No. 1 Assessor's Map/Parcel /a� s . o t ' (',G p V ec � ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Q--G 0 Ac VV Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other. Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank c-1 ((�/WA Type of S.A.S. r C Description of Soil t/th-F Q S,iAGc ( 1 Nature of Repairs or Alterations(Answer when applicable) G ✓ r Lr Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system t g in accordance with the prorov-i-s�.ns_of:T'tle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has' issued Signed - Date Application Approved by Date -- Z� " 1 Application Disapproved for the following reasons Permit No. — .� Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, at the On-site Sewa a Disposal System Constructed( )Repaired( ) Upgraded(� Abandoned( )by at L r z e(t✓ J —2 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Z J Installer Designer The issuanc f this pe it sha .not be construed as a guarantee that the s st 11 function as desi d. Date �^ Inspecto, 1� --------------------------------------- No. .�-�? Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpo5ar &pgtem Construction Permit Permission is hereby granted to Construct( )Repair )Upgrade( Abandon( ) System located at -r 57 Z ev and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction/must be completed within three years of the date of this p9qmt. Date: Approved by K' TOWN OF BA.RNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOTIV 3'L�.`�l INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /gOy LEACHING FACILITY: (type) �1 4 sue/ ZA *2 (size) T/ Y,;Z-f NO. OF BEDROOMS � p BOOR OWNER i -c`r2 PERMIT DATE: "2 �COMPLIANCE DATE: r.Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by n (� 1/6199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AYD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (W=OUT DESIGNED PLANS) o hereby certify that the application for disposal works construction permit signed by me dated ����'� concerning the pro pe rtY located at ` meets all of the following criteria: 6• The failed system is cone`ed to a residential dwelling only. There are no commercial or business �es associated with the dwelling. - The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. 6-/<e—re are no wetlands within 100 feet of the proposed septic system • Mere are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed Yere are no variances requested or needed. • e bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor hod when applicable] •/If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation / J the NIAX. High G.W. Adjustment . DIFFERENCE BETWEEN A and B SIGNED : � DATE: 2)1� (Sketch proposed plan of system on back]. q:health folder.cent . c✓ '` L 0 C A T 1�0 Ne ' SEWAGE PERMIT -NQ. VILLAGE lz J I INSTA LLER'S N M b E _ ADDR ESS ES5 k 1 . BUILDER OR OWNERL�s���� � L-CGr✓Z�� DATE PERMIT ISSUED DATE C0MIPLIANCE ISSUED } k3l� •��'ff?f FE0�............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........................................O F..........................------........-----.------------.............................--- Appliratiun for Dispersal Works Towitrurtiun Vamit Application is hereby made for a Permit to Construct (-/) or Repair ( ) an Individual Sewage Disposal System at: ....._... -.. L.._ :.- .. . �3 L...............................................:� .•--•--•-----------•----...--------......"� .....-•-•--------•----- --•--------- ..• •-- �{ Lo.ation-Address or.Lot No. ----------------------------- _..--------.. �'1�- Owner � Address ss7�—sen - f Z.....r -. .... C).-fo_x....L23........./?J�S?��s..1 ll's....aU Y57 Installer Address Type of Building Size Lot.... _-'!..,,`?. ?.2..Sq. feet Dwelling—No. of Bedrooms.......... .............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons--.------ ............. Showers Cafeteria G4Other xtures -------------------------------------------------- W Design Flow........... .. �� ------.gallons per person per day. Total daily flow.:.-�._®.............................gallons. WSeptic Tank—Liquid capacitylhW...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........................................ Test Pit No. I................minutes per inch Depth of Test Pit-----............... Depth to ground water-.---.-----.---.-------. f74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----.................... R•' -----------------------------------•-----------------------------------.....................------- -------------- --•----------------------------- -------- -.. ODescription of Soil........................................................................................................................................................................ x U -----------------------------------•--...._............---------------.....------------------•------------------------------------------•-------......------•-----------------------------..........---- W --------------------------------------------•------------------------------------...----------------....----------------------------------------.---•--------------------------------------------•-•---. UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------•------.........----------------•-------------------------•---------------------------------------------------------------.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT114 5 of the State Sanitary Code—The undersigned further agrees not to place-the.-system in operation until a Certificate of Compliance hakeen issue the -f-heal in -- ---------- ---- --- ------ ... ...----- ............................. ......... .... . ............ r �Application Appr ed ---- -- ----------------------------------------- Date Application Disapproved or t following reasons-----------------------------•--•--------------------•........................................................... .........................................................................................................I..............•-----------------------------------------------------------------------......--- Date PermitNo......................................................... Issued....................................................... Date M ------ --- -- --------------------------- ------------------- -- 1 No.-00— �° /..... FE _.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................OF............... Appliration for Dwpoa al Works Tonitrnr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ ..----•----•...........--•................-•--- - - ............................ Location-Address or''I.;ot No. ......................_.......................................................................... .............................;;,...=•-•---•--.....---•----......---•-•......•......0......-....... W Owner ",1. Address a ----...••...............•...........••--•---------•••-........._...................•.......... .............. =--...........•-•--•---•---•••••----.......•---••...._•••••••••-•--•....----••-- Installer .''' Address Type of Building Size Lot............................Sq. feet V Dwelling No. of Bedrooms.............................. )a g— pansion Attic.,( ) Garbage Grinder p, Other—Type of Building ...................... No fAP� s Showers ( ) — Cafeteria ( ) Other fixtures .......................... E` 1 .... W Design Flow................... ...._ gallons per"person per day. Total daily flow ...... ..__.............gallons. rw � ;° �� �' Septic Tank—Liquid capa6tye ......gallons Length................ Width................. Diameter ----_ ... Depth.......0........ Disposal Trench—No..---.. .•......... Width.................... Total Length.....................Total leaching area. ................... ft. Seepage Pit No..................... Diameter....----.....--..... Depth below inlet.---.-.-::....... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit................---. Depth to ground water..-----...........--.--. . 4M Test Pit No. 2................minutes per inch Depth of Test Pit---................. Depth to ground water........................ 9 --------------------•--•------•---•-•--------...-------•-------•----...---•...•-----••••-•-----••-•....-••••--•-••-----................•• ------- ....... O Description of Soil......................................-............................................................................................................................... x V ................•----------•--•---------...---------••---------•----•---------------••--•------•--------------------------•--•-----•-•------•------------•-••----------•-••--------••......-•------...... 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 TIT14 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation'until a Certificate of Compliance h een issue b theQ)oard of heal igned, -......�.. ---- •----- •--------- . 1.... Application Appr B ---•••-• ---•••-------- ......... --••.-- -•--•-. • -- -•-•--...._.. Date Application Disapproved r .111, following reasons:................................................................................................................ Date PermitNo.....•................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF Trrfifiratr of TompliFanrr THIS S TO CE IFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )F � by---.......;...: ::r- = .- --------- ...-••.................. Installer r at.- ------------------------------------------------------------ ---- ---------------------------- has"been installed in accordance th the provisions of T�,it, ��,j�of The State Sanitar C J scribed in the application for Disposal Works Construction Permit No................/-.--..............__.. dated_ .-- -.`;_ ____.__.-_-.--._----__.- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , DATE............ ........................................ Inspector........ ... -•-• .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FEE..................... �i��r�a o • �IT on iir�ion rrrani# Permission is her by granted......:............ .....•-- to Construct ( epair ( ) an/ dual ewage isposal stem atNo. = --........Z-jr------•--------... - ----- ------- . ----------- Street as shown on the application for Disposal ks nstruction Permit—N. .... ...r------- Dated.......................................... s ------------------- ----- -••------------------------------•--. 2 —0 J� Board of Health DATE OoC--------•--•----------------- FORM 1255 A. M. SULKIN, INC., BOSTON - \ .. Assumet T.R.M. C • ` / \ \ �.5 ����V�Q l/ STAGE NO EL= 100.0 102 �'Qo 9g,p No . I N y /0( N g H of 3 �s rb e ,rq `^ y rrb //4 H Of digs mb b I& a on R.HALL 03' IS, o00 5. F ,V/ O Z�l Zq.8 100,w r 0 Tl-I �vQ 2.0' FQOW T SET aA,== S1 be P- PEAL S. B. P �lr3T PLAID 1-X ISTI Q6= ELEVA- ow �c rrcuQ- PQoPCI-tr--t�, eLEVA-ncii e. cou70U(L LoT 18 � ��21 � QUAD • 25 r rJ APPRaED : E� P-D oF' 4EAL-rW os���/� L L-E- 2 kaqISe b a3.03.84 D4TE A6Eh17" SCALD= 01.o3,e4 cLIgLi : WA'LShI I uEQ.EBY 0. InFY'MATTlI - FQcx-z=� EFLL(S sAAJEYrW61 r0,%.. Jog US ; B4 . Io EUILDI1.16 sr4cnwU c)d 'Tl41S PLAT-J �Lq Mc15KEI�ET LAu>= Co►.1FoQMS To TI--IE Z(=)Q J6 LAWS DQ.8Y: OF BAaQSTABLE, MA55. c::�=-U7—=Q,1Ii 1 F, MASS•, o16'32 SUEET 1 . ,F 3 DAT1= rSMPED LAUD niWEfaR L107E : I E ITFd>✓ 1-4-4 E —_JE Pr I G. -N',J V- p(L r LEAD N 1 N b PIT A-� Moa:a TI•-I A e-I 12" -RA /� 2�{ - D I PriV1�� rim rD a�-c cx=> �P- / SHALL .r�. &4T 'TO GR,4pE D�rva=WAYS ✓ c�.�cf2>=-rl= / 4" Ric PIDi=• � QF�,tQ� ,4u t=xrRA NEAP( D�tr`�G4�r 12a..1 ��Z :: / M 11-1. PITCI-t` -Q /o M11.1 > G2ET� l CS aAD= cr-=>v� 4"C.45T � ✓ -a=--- —2'�LA`t�Q-oF' �s�- 3 1(2p> r PPE ,$A o e c.+ uJ�� wASk4ec> m I w. Pn-44 GAL. 1]IST. c 1 ° ° o ° o o a �/4' PE�a FT". 1�T-lG g ° p e l e -GT-I VE e e e 5/4," - ( 1��•" o - � • e e o e o ° r � 1 0 pp ExSE1✓PA�S7= e _ --- � PIT Y=CJc.)f1c l._ le-!�/EQT AT BLJILDIIJC= 113.0 Fr-r. FT D/AM. jh1LET 5>=PTIG TAE-t� I I�L•o FT IT CA-PAc.lr-( '. 490 v �D I FT. D I AM. C SEE TA BcX-AT10e-�� OUT LET SE Prl G TAe�1 I t I . 8 FT. —� pro 11-1 L'ET D I I Rxmor 1 �X ill . 0 FT S�C-r I�a_1 o F MAX G Rauu D wATE R T74i,L L= S. O o�LE r D,STQrt srlo-I lax I to. 8 FT. -r=:,F---wAGI=- D I SPcm AL M I LJ LET LEACf-}1,.16 PIT 104.0 FT. n n Prl DESl6tJ GKITI=ILIA 114' t I ' o DIMi=1.t�►o�1 A 8.5 FT. D I NI aW� I o+-t B FT. e.IUM P � oP ��Qrxy..�5 3 D 1 M 1=U SlC=Wj C 4 FT. M 1 eJ GA125A,sm- >5P4:aAL uLe17 . sloe-+i= �►L LoG - 7=11-a L E577&A ATED FI oW 33 0 I L 1=1 tiluMB cF Li=A4{erJb pe15 ouE L= 99.8 EL - 99,3 L4TC of 5o1L-rE-Sr �' 2S •8 I SIDE LEA�HIu6 FeR- AIT ISo.B �. Fr. I��M 2 �,t-nn �rYx,L-15Q�D I'�Y G rFFo�A Joe��S c- 6. T.s , 0- 2 @=>77MM LEA,-H I ub ��- T I 1 3. I C_ny. FT. e� T. S . C1=Q.CCL.A-n,=,j 2A-r= till- 1 -rpTAL LEAcN I N6 r�1' A 26 3, 9 Pe a O=LATo+-- tie" .iL TH^f-1 nn e u / e ucr-1 2ro 3.9 5r_a. �T: � �L- 0" MIL`5.�,•tD ° 2 -�i� Mom saND LEt�CN 1 tilb AO-MA SdeL T1=ST PzF P - 4(.S Pr=R Q LoT 2 8 Tr BEI-s��2 �-o,4D OFEV&I" OF j,4A wrR coon PS� G ©wTe-ccw PS e�5 f 1 LLB ti o\ tg 8 nN L• 9I . 8 ,F EL= 91. 5�- e�a . EU= y %. \ �C, ♦�O� C �� 19 MtJS6Er LAe.t�, L�->TE2�/rlLi=, MAS . 3TE vp A 1ST . til0 G Rp�u D wA-r=D-av--r �e.17E�D p4T� . 4. 3 s4 J MrtAR W* [�G 12ou�eD wA-e�2 a EL - -T I.8 WAcLSI-1 q PeR® v4-rf- co PS M L - 95.0 e),a -I o Sr-IE�'T IL. of 3 Permit humber: Date: U V Comp 1 e't,ed by HIGH GROUND-WATER LEVEL COMPUTATION Site Location: t� �.a�2�� , C ���LL1✓ Lot No: 'Owner: K=—la-� c--JALSH Address: IBIL Por.rD ST-)-E;_=T , QS.TSe.vic.L.F_ Contractor: W/A Address: Notes: ��� -rs�- F3-r , �o � 13r� aF 1-E�A�r�+ QoN 6 iFFa D p- 4(.5 STEP 1 Measure depth to water table to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (./45/al date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Aiw A) Appropriate index well . . . . . . . . . . . . B) Water-level range zone . . . . . . . . . . . . C STEP 3 Using monthly report"Current Water Resources Condit.ions" determine current depth to L24 . water level for index well . . . . .. (0 /SI mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP -2A) , current depth to water level for index well (STEP 3) , and water-level zone (STEP 213) determine 3,2 water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP 5 Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 4.3 level at site (STEP 1) . . . . . . . . IQf�_> �7ti1 �E. 1�IIGCE25��► J�,�t�e-i 3� 19Ea C� b-srQ coin P5 = 1 -5,2 = E L = 9-5 . a - 44= df= wa 84 - �o No.-- Fimic . . ................ THE COMMONWEALTH OF MASSACHUSETTS �. OAR® �p HEA TH ✓,..................OF........� ''r�1/ir�/& AVVlira#ivu for Diapntia1 Worse Tamtrnrtion Famit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at*7, - ._........... N............ C ..... .....--cati A dress r Lot caner Address Installer Address Q Type of Building Size Lot olo......Sq. feet U Dwelling—No. of Bedrooms---- ...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .................................. W Design Flow................�2.0...............gallons per person per day. Total daily flow............................................gallons. W Septic 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_�Cl<...sq. it. Z Other Distribution box ( ) Dosing tank ) '-' Percolation Test Results Performed by.--____ ��.C!!j..................... W Date.-y - e - - Test Pit No. 1�?�f '�minutes per mch Depth of Test Pit__��.......... Depth to ground water- Test Pit No. 2......2--_...minutes per inch Depth of Test Pit.................... Depth to ground water........................ �1 o , peX61 J i�-- Description of Soil ------ ----- ✓ ... ` P .. --------------------------- --••-•-------------------.2F.-------- �o%.q - -------------•-- ---...--------------------------•---------------------------------------....................... 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 1— 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee • ued by the b ' d of health. Signed. P. _ . . ....--- __�--_�................. Application Approved By_ mate ------------- -- Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------------•. ................. ......................................................................................................... ------------------ Date PermitNo......................................................... Issued....................................................... Date Ivo. .4/. __. 7o Fims..3....._............_. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for Uiipotia1 10ork i Ton rnrtion VarAft Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal ..................................................... .......................... ................67 � _........................................................ o at tz Addres r ] f o I of fl �.. Address Installer Address Tv pe of Building Size Lo ____ _.�??0.......Sq. feet V Dwelling—No. of Bedrooms___ _.__.___ Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria a' Other fi tures --------•----------------------- W Design Flow............... ................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ e th__.___________-- x Disposal Trench—No_ ____________________ Width_._______._.__._.__. Total Length___.__.__._.._______ Total leaching area_._.::..___ _____..sq. ft. Seepage Pit No--------------------- Diameter...........:........ Depth below inlet.................... Total leaching areae! _ ....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test R Its Performed by.......... __. Date________.______..__._____.____.._..___.. --- ------- --------- f------ aTest Pit No. ,-:....Jr minutes per inch Depth of Test Pit? ............ Depth to ground water'lW!? _t`''VtG.fr; fi Test Pit No. 2....;!:"''......minutes per inch Depth of Test Pit____________________ Depth to ground water....................... P4 ....... Description of Soil.0 J41 ----•--....•------- ----lar9. e,. ........................................................ U ----------------•- !� i t s 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:i:i" p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeix'`Nsued by the�,be rd of health. Signed1 ---•-- ----- - •-•- z'� /'`� s� ��► ate Application Approved By------ Y d----- -�� ��f r Date Application Disapproved for the following reasons-----------------------------------------------------------------------------•--•-----------..._---------------•- --------------•--.--......--------------..._._-----•--------•----•----....---------------------------•--.-----------------------------•---------------------------------------------•----------...--•--- Date - I PermitNo......................................................... Issued-------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H ....,�:...... ......... OF... ./ ..44....'y.... Cwrrtifiratr of Tomplianrr THIS IS TO CERTIFY, That theAndividual S age Disposal System constructed (K) or Repaired ( ) by--------------------_-----,, .. ' ..5..------... ��(' �, j ----Syr.------....._.....A.........._..--•-----.--�-----------------j--.---�---...----------------..... at......................... --- f------ --fs�i!----- •� /"•^M✓r l'�'�'1`,G ..... has been installed in accordance with the provisions of TII;'IZ r of The State Sanitary Code as described in the application for Disposal Works Construction Permit No(-.. I --- -------------- dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................. 1-21P1"��.................... Inspector.. --Tr------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE�ALT.H i ................................ ............ ............... ., Ravolial Vorkii mitnuton ranfit Permission is hereby granted_.._ '? _ ......... 14 to Construct. or Repair ) an Indi idual Se wa e Dis osal �S,ystem at No--------------- � - '_ - ', !' '.._...r. / Street as shown on the application for Disposal Works Construction Permiitt� No..................... Dated........:................................. --------------•------------------------— rd o�Health DATE ...... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS .L 3 /f 4 cnk __0 • � _ Mir , ' G : u N- $1 , , . w i - r jK -e� i L EGENb -M s, ,. , EXt9ttIN0 S POT ELEVATION Oxa �w oFM, CERTIFIED PLOT P :`AN EXI STING -CONTOUR _ z ��L .� FINISHED SPOT ELEVATION. ?d Ro��a . c `FINISNE0 CONTOUR --4-- 0-�- -- :' /�Id FOVED. BOARD-;. Off' MEAL � ,� 0.22162 Tip �, -GIs1`E•P��`� - ;. DAtL�,_ :: AAENT' S ' :.., * .9CALEI 1, + Y� , bAT L REDQE- ENG/MEERlNG Cdt'l �t �r���� ,pbr�,� CLilNw"f''� , WHAT „THEE` F 0PO8ED 818TERE ltEblBT�> ED 0 3 BUILOINB SHOWN �!N_•THIS PLAN C1VIL LANb �Ob NO. > lB.IW`E fly `` T " /S CONFORMS TO THE :Za'N`iN© LAWS` ` �t w U y DIt BY* �� ., 1F. ISA!N:SY `®LE,. MASS. ' NF, t ?I8 ;GAIN•��`. CH bYt N f �YAA S...MAS i y �� � �TE ;�E'�f. IAAtD" `SURVEYAtt . . 20 FT. M/N. ,_ n NC77F'.•: `/F E/ rNER THE 3EPT/C TAN�/c DR �,LEffCXl�1lG `PIT.ARE MORE :TNA.N /2 $rEL0 /G F7 M iN. RA OE, A 24-,0 W TER"'CONCR°4 TE COVER: { • SiyALl 8E ®ROu6HT ,'TO'GJ;AG.E.�i9N-EXTRA } 4�PYC P/PE CONCRETE /7F46,4Yy CAST ✓•QON CDYER .SHALL 8E US .C� M/N. P/TtN . CODE _ a !F/.IV L>R/YEJyVA Y. . : P J M/N CONCRETE , G[EAIV SAAl,0 iT— BA.GICF//L L. �• _ LiQU/D LEVEL f -, a' 2 SLAYERFAS t b ,M/N.P/Tt'/I 0 a aee OW /PF U� G11L. ' ! = ! .::• • • +1 a v o jtil�tSNEO SANE } s r•°� %s SEPT/C TANK D/ST , ! • "• s. t • •�. e a s o. WAS/IEp:STONE s. 1 • . ::• • # a 0 4 010 P PRECAST SEEPAGE 0 1 s+ 1 • ` +• .• s P/T DR 4MU/Y.. YAW /1VYERT AT 011/4O/N6 FT. �� f� J.NLET' 9Ji S PrIC TANK fT. a .,FT. ,p/ C CSEg 7IdULAT/CN� b.. OUTLET S.EPT/C TANK- aSy 3 FT. 6NGET�ISTRI®�/TION BOX aS�O f-T GRDl1No 47ER TAaLE' =iy,9 SECT/�N GF' t9(JTYETDJSTiq/®(/T/©JN BOsX FT. ' �-. w 1"4.07" LEACNlNG I0'I777 FT, SEAVAGE .,015R"A4 SV.57-jffM aLEACt�/!V6 P/3' A � J SCAt_E Y T - ,DES>GN ,Cft/TEI'!/�l - - 1+'lUMO�ROFDEORoo�Is 3 � t»�Easia/y .�_G. `��7:'�� GARQAGE D/SPOS✓I L VW I r sou- LOG T TA4 ffSTl#WA"rEo F40*V G.4L. p,4Y SO1L TRST / SO/L TlL�5T ,2 $O!L TEST., Nl1maze AF t,EACNuvG ,o/TS_- ` �2EY. 4S�4. Ar4ff 0A'rLr'.op So/�. TESL' /, f S'/L>E L.EACH/NG PER P!T ��� PT. � � .: ItEsutTs rvrr/V�s3ED dy :�C� � .► ;. dorm/Argcti/lNG PER P/T 7 P $Q, pT. LeM..iS�.6 s 'RCOLAT/Oiv '9l�4T� i /iSf /!�/A+ JNC# TOTAL lEAC/y/NG AREA SQ. F.T. �-� FWleCOLATIGlV VA. .. RESERVE LEACHING AREASQ. F77 v+ M / /lo�,yRo Assgc S LI7 + /a.a:3�•. s m!!/d. i ' i o P. rn j S�N� avNr�crs AFL. IC F/NGJNE,mRI G,.0 t,I►�VG. o F No.22162 Q 3. G _ C/STE���`'�� LJ H)'.4NM/J `AIAsfi Fr��ONAL EN6 {� NO GROUND Yy&Ar ENCOIJ/VTE!et , Q -0mo uAvo yvATE.p.AT EL.E�/. ' .JOB` D<, /B� ► - -_- K• LOCATION � �� SEWAGE P RMIT NO.� VILLAGE A - 113 051 INSTA LLER'S N ME a ADDRESS I B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � _ a7 -235 v.� ALWAYS DIG SAFE PRIOR TO CONSTRUCTION--UTILITY LOCATIONS SHOWN INCOMPLETE. JOB NO. B11-03 NOTES Baker3.dwg Rte. Lj�j 1. LOCUS IS A.M. 298, PARCEL 48. 6A ' � FB26/55 SB12/49 2. ELEVATIONS SHOWN ARE ASSIGNED. w cli 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED AUGUST 19, 1985. o 4. ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED) Maras in (too a 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER. ca 6. COMPONENTS TO BE AASHT(3 H-10, UNLESS NOTED. o co a 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14". 0 8. IF TWO OR MORE LINES, WATER TEST D-BOX FOR EQUAL FLOW N/F m D-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET. 73 CHAPMAN z 9. DEPTH OF COMPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. NOT TO COVERS: BUILD UP COVERS TO 6" BELOW GRADE--2 ON TANK, 1 ON D-BOX, 2 ON LEACHING. x/43.73 a SCALE BENCH MARK-TOP, BACK, CENTER 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2" PEA STONE ON TOP. SEPTIC TANK=45.34 ASSIGNED 11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND, LOCATION MAP CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC. F 4 12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING x 44.8 IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR 15.255(3). ' x 44.4 N 8035•33., W 13. PUMP AND FILL ANY EXISTING CESSPOOL/LEACHPIT. REMOVE ANY CLOGGED SOIL, BLOCK, TEST HOLE 2 LCJ 167.14' x 44.9 AND STONE IN LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. 14: ALL CONSTRUCTION TO MEET TITLE S AND LOCAL REGULATIONS. DEPTH (inches) ELEV.(feet) { N /F 0 47.0 46 `r GAB/ANA Fin TEST HOLE DATE: November 7, 2011 x 45\ 6 1 x4 5 6.5 45 8 NO GRADE CHANGES PERFORMED BY: Ron Cadillac, Soil Evaluator 15" 1 ARE PROPOSED WITNESSED BY: Donald Desmarais, RS y y / 1 lay er e��.5 5 6 �- 35 /� ( layer) loam sand r - PERC RATE: <2 -00 Inch C la er ' 42.29 46.0 i SOIL SURVEY(1993): Plymouth loamy coarse sand 48» 43.0 GEOLOGIC MAP(1986): Cape Cod Bay lake deposits 4 .5 46.98f a, C2 layer 2.5y 6/4 Q. 47,1 47,4 47.8 Top Foundation� 10 HI-CAP INFILTRATORS/ , o Invert 44.10 medium sand ICJ o Z r_ '-\x 46.7 c18 Use Gas Baffle Invert 43.36 o x 43 5,3 r Lci 1Q _�� i i Top Units=43.7 I &V N ~'' _ -' Proposed � 48,8 9" min. cover ® Filter Cloth 20' x _______ __ L----�� 3" Max. I 0 � � 47,6 LOT 37 Existing I S=2"/ft I �' 46,5 48.9 g S=4"/ft �/Inspection Port x 41.2 1 x 49.3 1000 Gal. r C-) v� C ----- i -- Screened Vent / 41.06 ~�-- 05'S Z p Ex'St. 1li 22,0� 0±S.f . i Septic Tank \ �/ Deck i x 6.% 48,4 L----------� 11 130" no water 36.2 TH Z x 40.86 G \ W 46.4 1i 8.6 Invert 43.53 Invert 42.70 40.96 483 = TH 1 `? .`" 6" Stone or compact Proposed Proposed 5.16 Bottom TEST HOLE 1 PAVED D :: - _ x 47,2 �s x 50.3 N I I I I RiV 7 W� �, ,°'� N L 3' -� N►i-2-� Bottom TH2=35.8 DEPTH (inches) ELEV.(feet) x�0 32 "-42 99 �� 0) m 0 46.6 D T PARKING r4�-14 / x 46 � 64 �� z DESIGN DATA Fill 15" 45.3 - 44.7 9 20, ��' PITCH INFILTRATOR x 48,9 BEDROOMS: 3 LEACH AREA 44 �-�0,1 � x �6.8 GARBAGE GRINDER: No x ,7 TO KEEP INVERT I �� 48" BELOW GRADE REQUIRED CAPACITY: 330 GPD (SEE MODIFIED CERTIFlCATION FOR GENERAL USE--REV. 6/30/10) 45.4 x`sy VENT EXISTING SEPTIC TANK: 1000 GAL. EXCAVATE A 2'-10" BY 62'-6" TRENCH. USE 10 HIGH x/39,6 5A / EFFECTIVE TRENCH LEACHING AREA: 486.8 SF CAPACITY H-20 INFILTRATORS, AS SHOWN. FILTER CLOTH C2 layer 2.5y 6/4 x 46,6 71 IS RECOMMENDED OVER UNITS. BACKFILL TO TOP OF UNITS � 9.59 44 1 45.88 7.79 SF/LF X 6.25'/UNIT=48.69 S.F/UNIT WITH CLEAN SAND FROM A GRAVEL PIT, OR VIRGIN C LAYER medium sand 7.2 46,5 10 UNITS X 48.69 SF/UNIT=486.8 SF(EFFECTIVE) FROM SITE MAY BE USED IF IT CAN BE KEPT CLEAN AND 0.7 x 47A DESIGN CAPACITY. 360 GPD 42 CO [(486.8 OF TOP AND SUBSOIL. [(486.8 SF) X .74 GPD/SF] 173 04' S 77 34 22" E x 4 2. N/F INSPECTION SCHEDULE 130" no water 35.8 44' CERUTTI CALL R.J. CADILLAC TO INSPECT PRIOR TO BACKFILL. 1.9 N/F GLARNER BENCH MARK--TOP OF STAKE SET FLUSH=45.88 ASSIGNED BDRM BDRM LVRM (28' OF GARAGE CORNER & 43'-9" OFF DECK) N/F DOHERTY GAR KIT DNRM BATH BDRM SITE PLAN BATH FOR FLOOR PLAN THIS PLAN IS A VALID COPY ONLY IF IT BEARS NOT TO SCALE AN ORIGINAL RED STAMP AND SIGNATURE. LOUISE MAE BAKER LEGEND ,: -'�_" OF �S � ;` - q s LOT 37, 19 CARRIAGE LANE, BARNSTABLE, MA TH 1 TEST HOLE LOCATION, NUMBER (I ', ��� N L�9cy� N L q G N OVEM B ER 18, 2011 SCALE. 1 "=20' W WATER LINE MARKINGS \ dA UE UNDERGROUND ELECTRIC WIRES (IF SHOWN) CADILLAC CADILLAC G GAS LINE MARKINGS # 1060 0#35779�� x 9.5 x$,7 EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT) Fc1$TEg� �q�FEss\o 0� SANITA?,\ �_SURVE RONALD J. CADILLAC, PLS, RS, P.C. EXISTING CONTOUR $--- PROPOSED CONTOUR �rZ IT-7 PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN 0 UTILITY POLE (IF SHOWN) P.O. BOX 258 ® EXISTING DRAINAGE CATCH BASIN WEST YARMOUTH, MA 02673 x - FENCE (IF SHOWN, NOT ALL SHOWN) (508) 775-9700 0 TREE (IF SHOWN, NOT ALL SHOWN) HEALTH AGENT APPROVAL DATE ©2011 BY R.J. CADILLAC PAGE 1 OF 1 -- T