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HomeMy WebLinkAbout0050 LAURIES LANE - Health 02740.5 Marstons Mi► i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is Marstons Mills Ma. 02648 10-3-2020 required for 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:When A. Inspector Information Sl# / Ild-- filling out forms on the computer, use only the tab David J. Burnie key to move your Name of Inspector cursor-do not High Tide Septic Solutions use the return Company Name key. 3 way � Company Address Harwich Ma. 02645 City/Town State Zip Code 774-216-1440 SI 386 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes �S�o0%jillIII 0 3. ❑ Needs Further Evaluation by the Local Approving Authoig. DAVID v Z {"... = O: C?i. rNIE 4. ❑ Fails _ S136 / A'. n . 10-3-202(�,oF 5 ►n�S P EG.��`�� Inspector's Signatu Date "/////4 fill II11110 W. 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system is working as designed. Tee's are in place and the tank is at normal level. 2) 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): t5insp.doc•rev.7Y2&2018 Title 5 official Inspection Form.Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is Marstons Mills Ma. 02648 10-3-2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ ND(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): 3) 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. a. 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: t5insp.doc-rev.726=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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: ** Y This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal ICI 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No II Backup of sewage into facility or stem component due to overloaded or ❑ ® p 9 tY Y 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts r Title 5 Official Inspection Form Voluntary for Subsurface Sewage Disposal System Form Not f Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ '10 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is Marstons Mills Ma. 02648 10-3-2020 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ E 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 Elapproximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc-rev.7/W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owners Name information is Marstons Mills Ma. 02648 10-3-2020 required for every page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 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): 353 gpd Description: 1000 gallon septic tank, distribution box and 2 leaching 500 gallon DW. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): yes Detail: 2019=22.000 gallons=60 gpd.......2018=60.000 gallons= 165 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I� Commonwealth of Massachusetts r Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon septic tank. The tees are in place and the tank is at normal level, ICI If tank is metal, list age: years � Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 24" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4 inch Distance from bottom of scum to bottom of outlet tee or baffle 20" How were dimensions determined? tape and estimated 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 at normal level. inlet and outlet tees are both in place. The tank should be pumped for maintenence. t5insp.doc-rev.7/26/2018 Title 5 Official Inspecon Form:Subsurface Sewage Dis posaI Systern-Page 10of 18 I Commonwealth of Massachusetts �s Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 18 Il i Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is Marstons Mills Ma. 02648 10-3-2020 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): Clean and no leaking t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Located and found no standing water Type: ❑ leaching pits number: ® leaching chambers number: 2 500 gallon dry wells ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Tille 5 Official Inspection Form:Sutuurtace Sewage Disposal System•Page 13 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 lauries In Owner owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): None. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Launes In Owner owner's Name information is Marstons Mills Ma. 02648 10-3-2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I t5insp.doc-rev.7/2 MIS Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 I` Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner Owners Name information is Marstons Mills Ma. 02648 10-3-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 �I t5i .doc-rev.7/260018 Title 5 Olfidal kmpeciim Fomr&bmvlaw Sewage Disposal System-Page 16 of 18 _ .TOWN OF BARN$TABI:E , 1 LOCATION 3�O AAO)V4S A,*A)E SEWAGE D VII.I,pGE �5�"Gtt� /J'I!L ASSESSOR'S MAP&LOU27—IoS� RMALiER'S NAME 4 PHONF-NO. SEPnc TANK CAPACITY /-OtM 6.A c C. aA> % LEACHNG FACI ny-(type) 4AC•Cdht)C&/Y/�IK�lsize) l 54&5 -NO.OF BEDROOMS BUILDER OR OWNER PXRMFr]PATF- 7 $ O� _COMP CE DATE: Separation Distance Between the: Maximum Adjusted Groundwm r Table and Bottom of Leaching Faculty Private Water Supply Well and Leaching Facility (if my•wells exist on site or within?.00 feet of leaching factlity). ' Feet 7(DD Edge of Wetland and Leaching Facility(if any wetlands exist Feet within 300 feet of gg jfa�cttity r Furnished bp. �� ��� NO US F rs �o KC 04 4- 48, �sQ� AS=sr, 6 � Joryp snc�•d . i . `td r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner owner's(dame information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 11.25'+ 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. 7-12-04 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: plan on file BHd dated 7-12-04 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file BHD dated 7-12-04 dry test hole to 11.25. Grade at test hole is 88.90 the bottom of the leaching is at elv 85.90. The bottom of the dry test hole is elv 80.05 this allows for a 5.40'seperation of the bottom of the leaching to the dry test hole. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2812018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 I •Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Meg Merchant Property Address 50 Lauries In Owner owner's Name information is required for every Marstons Mills Ma. 02648 10-3-2020 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable � r o Regulatory Services _ Thomas F.Geller,Director Public Health Division • Thomas McKean,Director 200 Main Street,Hymnis,MA 02601 Office:.50&862-4644 Fax: 509-790-6304 Installer&Designer Certification Form Date: Tf r - Designer: , Installer: 21 c Address: . 43 Vide STRea r Address: 0, 096a On -02$-O, was issued a peanit to install a (date) installer) septic system at SD bi-V«S L"i= based on a design drawn by (address) 1e• . - dated -7—za- (designer) -z-�- XVicertify that ffie septic system referenced above was installed substantially according to the design,wbich may include minor approved changes such as lateral relocation of the distsbution box and/or septic tank I certify that the septic system referenced above was installed with major changes (Le. — V=ter than 10' lateral relocation of the SAS or any vertical relocation of any ent of to septic system} accordance but in wilh State&Local Reg"ons. revision or certified as-built by designer to follow. Z F DA EYER w er s Signahae) No.1140 Fo�s�a� (Designer's Signature (Affix Desiggner's Stamp Here) P t'R TQRN TO ABLE I'IJBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE 'WILL NOT BE aSSiIED UNTIL BOTH THIS FORM AS- BIIIZ.T CARD ARE'RECErVW BY TSItiE BARNSTABL N.PUBLIC HEALTH DIVISION THANK YOU. Q.HeaftlgegtimfDedpa-Qitifrcatiam Farm P Commonwealth of Massachusetts Ua - ' bS p Title 5 Official Inspection Form i � >? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments so L—•Gi N ✓/Q u Property Address A/A s He, N s lee- OwnerOwner's Name information is +/ required for every QYhs I( S " page. City/Town State Zip Code Date of Ins ection 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:When A. Inspector ector Info tion filling out forms P � 51.H- (,33 d on the computer, / ' / use only the tab A,4 Q (se,/ key to move your Name of Inspector ���! O %E cursor-do not c use the return Company Name �J / G/�/J key. ��/ >D Company Address l L-c)s7' Co.r61 a� Ci fro rc,aro �' /O State` _O Zip Code. Telephon umber License Number B. Certification I certif y that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CM 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that;�=assess 1. Z. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's f ignature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments viz I S� L�ur�e s L •r/ Property Address He ti S l le r Owner Owner's NameA information is /� ` � A 4 JAY required for every page. City/Town State Zip Code Date of spectioK C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System ses: 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: 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4V) Property Address /Ve N s ler Owner Owner's Name Q information is ,vsws' A-As /¢ Oa6� p p2Yltf required for every page. Cityrrown State Zip Code Date of In ectio C. Inspection Summary.(cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): El obstruction is removed Y N ND (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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u!� 0 au✓ce s Property Address SS Aer Owner Owner's Name NeN information is ,��f1_� '/ 0 6 v� required for every TV I page. Cityrrown State Zip Code Date inspeoffort C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El �ackup of sewage into facility or system component due to overloaded or u 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 t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments So a tines LAl Property Address OB Ile,N SS e✓ Owner Owner's Name �Q information is required for every page. City/Town State Zip Code Date of fspectKn C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ St iquid level in the distribution box above outlet invert due to an overloaded r clogged SAS or cesspool El Li ' depth in cesspool is less than 6" below invert or available volume is less an 1/2 day flow ElR ired 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 �{�,butary to a surface water supply. ❑ r _.Any portion of a cesspool or privy is within a Zone 1 of a public water supply ell. ❑ y 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 d chain of custody must be attached to this form.] V: 1�;❑ e system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 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. 5) 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 CA. 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 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts 1. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v�0 iu r�es L-41 Property Address ON Ile- JS er Owner Owner's Name /4/ k /V information is NS required for everyA1164164 'V page. CitylTown State Zip Code Date of nspec' n C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes ❑ 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? ❑ the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s0 � uries Owner Property Address Ile W ss er Owner's Name information is ) '7 required for every .4rs4 r1 , DOS 6 q i' � �✓ page. City/Town State Zip Code Date of Irfspectiorf- D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 3V Description: 0 /'000 6�' //0 S I`rl,,*) L (Q N v iff/'/'1 I.XI o v, 'O z7s r.0 O f,4/vH (i NON f ' ✓ ovu- l3.�a.5 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes to — If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes No information in this report.) Laundry system inspected? ❑ Yes Vo Seasonaluse? ❑ Yes < Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: G(.4 /',eh Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments S'D . zaLArA&s L-n/ `J Property Address Ile 14 Owner Owner's Name information is a f s 0 6 YB required for every page. City/Town State Zip Code Date Inspe tion D. System Information (cont.) 2. 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? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: pro 1?— ptvkw- Source of information: Was system pumped as part of the inspection? El Yes �No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -. s0 �curW-S Property Address He wsske Owner Owner's NamA&S400f information is // MY ��`�,O ,� 1 ? �/�required for everyI O W page. Cityrrown State Zip Code Date qf InspeOrion D. System Information (cont.) 4. Type of em: 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): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: p g feet Material of construction: cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,1-� Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments so Property Address Q r Owner Owner's Name (4 information is q���f /'s.f required for every (J b page. City/Town State Zip Code Date of frispectibn D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet ; rteial 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: S Sludge depth: YS Distance from top of sludge to bottom of outlet tee or baffle C 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 — How were dimensions determined? D l! A Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): / 4.4 / GEC _ I&eS 0,0 C/ COH 6rho*j. Le t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'Sig Za L4 f W Property Address ReW S S Owner Owner's Name information is ��0 N f t 6�� '8 �,� 41, required for every 7 page. City/Town State Zip Code Date of I pectin D. System Information (cont.) 7. 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.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SO Property Address Aw- Owner Owner's NamW4r"r4-0-ur He—t&y information is �' s � d�qg required for every page. City/Town State Zip Code Date 9 Inspe tion D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts fi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SO L un1" L— Property Address Ile LA-sS e� Owner Owner's Name /1 information is aj• rs �`[ Qa6Ya 'l� / required for every page. Cityrrown State Zip Code Date of j specti n D. System Information (cont.) 10. 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.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type Sao V l/ON cYI4t"0411 as�Q ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -- t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 13 of 18 Commonwealth of Massachusetts lip Title 5 Official Inspection Form ji Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S9 Gu0e Property Address /Iew f- JS i4er Owner Owner's Namlllar4yp information is f required for every page. City/Town State Zip Code Date of In ection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): o✓►di r? 9 �o vh ✓� N+ 41 1$4(1111 oe OA0 Ary 074e- *0 a-Ir C'6. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S Property Address nn Owner O G�s�r wner s Name information is a/Y s t 0 W � required for every j page. City/Town State Zip Code Date of I spectio D. System Information (cont.) 13. 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.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name /• ^ ,!'`� �c information is required for every page. Cityrrown State Zip Code Date of Inspe9flon D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view the sewage disposal system, including ties to at least two permanent reference landmarks benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buil ng. Check one of the boxes below: ❑ and-sketch in the area below drawing attached separately t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments So .-,4a L4 rill c, L/i/ Property Address Owner Owner's Name / information is 1 required for every rO�f S ` y page. City/Town State Zip Code Date of In echo D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells col �Estimated depth to high ground water: feet �[,ove, 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 ❑ served site(abutting property/observation hole within 150 feet of SAS) Check 4A ith local Board of Health- xplain: 1ps � 4 r (,�sf fib 5 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must desc ' e gh �ou established the high ground water elevation: chc C s l✓f ZI -Ifc. aTTt J on �Ul 4-e 94,16 4:1 X110-N A . fll Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 u Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Sig A. 2vtSs�r Owner Owner's Name / information is .7Lp�f 0d 6(4 required for every page. City/Town State Zip Code Date of Inspectidn E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked Ee�C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (F ' re Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIROI�I%NTAL PROTECTION `NSA C>z� F TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 50 Lauries Lane l Marston Mills, MA 02648 pSSESSORSMppNO' Owner's Name: George&Betsy Colby Owner's Address: PARC�,NO' Date of Inspection: July 6, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: July 10, 2004 The system inspector shall submi 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Lauries Lane Marstons Mills. MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system wi I I pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 1 1 ti OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Lauries Lane Marstons Mills, MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Lauries Lane Marstons Mills. MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Lauries Lane Marston Mills, MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period ? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined ? (if they were not available note as N/A) ✓ Was the facility or 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 Lauries Lane Marstons Mills. MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Private well Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 2000-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for um in : P P g TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 5113185-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Lauries Lane Marstons Mills, MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: S" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 v OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Lauries Lane Marston Mills, MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. Solids were present. The concrete was breaking down. The D-box needs to be replaced. _ PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address: 50 Lauries Lane Marstons Mills. MA Owner: George&Betsy Colby Date of Inspection: July 6, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 a� 1.) 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.): The leach pit was full Liquid was up into the riser and solids were present. The cover was 15"below grade. The bottom to'Urade was 9' The leach pit was in failure CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 s Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Lauries Lane Marstons Mills. MA Owner: George& Betsy Colby Date of Inspection: July 6, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. will 0 �So A 0 A Q a *3 S � 3 qy Iio 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Lauries Lane Marstons Mills. MA Owner: George& Betsy Colby Date of Inspection: July 6, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showing approximately 50'+/-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OP BARNSTABLE " FdQCATION So 1AU(1 cS 1��. SEWAGE # �77LAGE M. M►I1S ASSESSOR'S MAP & LOT MTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��ND ,*-LEACHING FACILITY: (type) P"r G x 4 (size) /M NO.OF BEDROOMS 3 BUILDER OR OWNER 016 PERMITDATE: 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 leach' facility) Feet Furnished by w�11 O :4'i 3 qy I �0 3 TOWN OF BARNSTABLE LOCATION J U-rlf'5 SEWAGE# i)d - 77 VILLAGE&A 2.59-0,92S In1L.4. ' ASSESSOR'S MAP& LOT D 27-l�S IATALLER'S NAME&PHONE NO. t Cu Q wJ SEPTIC TANK CAPACITY OVO 6�A L C dA . LEACHING FACELnY: (type) A-6-M (4(-Cd1d C/ 9—)?size) IvO.OF BEDROOMS .3 t �* ,'3UELDER OR OWNER tTc O -t &e&z CO .610 PERMTTDATE: 7'o?l - �� COMPLUKCE DATE: 3 0y Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet \ Private Water Supply Well and Leaching Facility (If any wells exist lezl&�nv on site or within 200 feet of leaching facility) ' Feet?JaA Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lea hing facility) A Feet Furnished by , - 1 4- 419 41 i I�ls=5�', � -1 ��CLo� '1 - box ! pnw 5 No. T -� ' Fee ©C) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE.,ZIpphration for ig"Upgrade,( *pqtent Cottgtruetioner//nit Application for a Permit to Construct( )Repair( )Abandon( ) ❑Complete System Eft dividual Components Location Address or Lot No. 5'0 /G,0�C//Z/i65 r«'*VZ �Owner's Name,Address and Tel.No. O3�2 I/)wesro/U�' /W ��[S, �Ifi. /11i2 �sG/a/—S Gc Assessor's Map/Parcel `�f,O O M-VA_,ST/URJ 14e- taller's Namey,4ddress,and Tel.No. S40$-t 33 0Q oc I Designer's Name,Address and Tel.No. yZ IC*A-iz0 /V-/)I/�c�i�►l 3 r/i�vF Type of Building: yt Dwelling No.of Bedrooms Lot Size U'J 'S .ft. Garbage Grinder Other Type of Building Z L; ifdam&,P, No. of Persons Showers(— ) Cafeteria( fi Other Fixtures Al Z.04V Design Flow l/0 gallons per day. Calculated daily flow „S.S gallons. Plan Date 7— 11—0 y Number of sheets l Revision Date " Title ,/�'2' f S iFcy/�lrE ZA Size of Septic Tank Z.t oA) Type of S.A.S. `5'00 e;44&J CAV4,0.04 < a � � Descripti n of Soil o �a S " /D — `y6 i� / "- >3s / r «� CDat rSr cc 10, Nature of Repairs or Alterations(Answer when applicable Tc G 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 t nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been' b t ' a —a g—U igned Date Application Approve6y Date P �� Application Disapproved for the following reasons Permit No. 3 Date Issued . / "No. C� c/Y ".e ( w . ° * a:' P 'p Fee r / 4 THE COMMONWEALTH OF MASSACHUSETTS En in computer. V Yes :P;UBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS `' _ ZIPPYication for �Digoo ' Y_6p.5tem Construction 3permit Application for Permit to Construct( )Repair( )Upgrade( )Abandon( ) EJ Complete System 1 4dividual Components a Location Address or Lot No. S"U AAv/Z/65 AIR k)Z Owner's Name,Address and Tel.No. Cfla : -03 16-9 f�}le 5 7-0.0 /V'R, ,1/7//75-. Cow 0 y Assessor's Map/Parcel o Z'I 02 ' l os— `��1 /Y�o9�sravdzA Installer's Name 4Address,and Tel.No. <-B 3-3 o� U Designer's Name,Address and Tel.No. t5 U`t21� J C CEi/��'/BU Z /?. SG- 1Z Z V 3 //i /E-5 Fcz �c . � h� . 10v 5C ZR-44e, Type-of Building: f)) Dwelling No.of Bedrooms Lot Size o2 -7CV/"s .ft. Garbage Grinder(--7— Other Type of Building n k"5/Zrk( No.of Persons Showers( ) Cafeteria( ) Other Fixtures /!s`/Ar l Design Flow �0 gallons per day. Calculated daily flow 3_ y� � gallons. Plan Date 7- /a^ 0 �Number of sheets l Revision Date Title 5 /�' 1� S�ul.a 6'E /-1At) Size of Septic Tank s &4 L 1 Type of S.A.S. -5-00 6446ad 6/4/4A7,eZ;e5 / Descripti n of Soil (A y6 /L�r�//ern CDCxrsc s�i" oZ /_ � .'Sec etc Gg Nature of Repairs or Alterations(Answer when applicable) E_ 4- L- D r/30 w SC71Q 6-/9 L e-D C /?i ,C 51 / 00 S e Q-110 jT242,17 o0 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 oft nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee b d ri! ned Date _a g ^ /Application Approve Date &ffAotl Application Disapproved for the following reasons r- - ` Permit No. Date Issued 0 ——————————,��——————————————————————— - - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFyY,, that e On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( by u t N , (�v u ✓i at c) V tie S "4 Q ,�� ,,j A4.` l , has been construct n ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. (may_3_77 dated -AWL Installer Designer The issuance of Ns �it shall not be construed as a guarantee that the sy t in11 function as own d. �f c Date _ t 0 L� Inspector pu —————— ——————————————————————————— No. ac�q —3 )r Fee U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Diopogat 6potem Construction permit Permission is hereby granted to Construct( )Repair(�)Upgrade( Abandon( ) System located at J`^C) G4 w�'�-S l-h . �' Y)') 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 mu t be,completed within three years of the da e of this Date: G Approved by a Town of Barnstable "E'°'��: Regulatory Services Thomas F.Geiler,Director + BARMAI= Public Health Division i6 . Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: ftLnr 3�2 AA Designer: DAU P_PI ,"(• Installer: Address: . 43 Vide STREP--r Address: E6, 3d>(/ "bVX&Vgq PA 0233r A-6 naRr f354¢`,e, On- 12-2$- U was issued a permit to install a , (date) (installer) septic system at 50 LAVUE-S LAAE based on a design drawn by (address) 0 M.M6 64 k•S- dated `7 (designer) . X1-certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocationx of the SAS or any vertical relocation of any pemponent of the septic system)but in accordance with State&Local Regulations. revision or certified as-built by designer to follow. DA cy4 --- � (Installer's Signature) EVER No. ER �F140 QISTEREO m M!%� NITARIP� 2 TYLA (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BALSTARIN PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE Wn L NOT BE ISSUED UNTIL BOTH -THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form h . '. .-.._. _ TOWN OF BARNSTABLE LOCATION J C7 UIT 14-5 I +A') E SEWAGE # Db`�- -7 VILLAGE aA;e5 g /n14 L-57 ASSESSOR'S MAP &LOT ©22405r INSTALLER'S NAME&PHONE.NO. Z IC a. C,9,7 J7 SEPTIC TANK CA�ACIT Y /�G"Z717 CA 4 C d,00 LEACHIIdG FACII.ITY: (type) ` 64C CdIA) C t�f1Y/� size) -NO.OF BEDROOMS ±± BUILDER OR OWNER CTr ' 1 c G P,ERMIrDATE: 7 tQ$ C1L COMPL CE DATE- D Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist n on site or within 200 feet of leacmpg facility). Feet7JO6 Edge of Wetland and Leaching Facility(If any wetlands exist / within 300 feet of le binili Ag,/facty /4 A Feet Furnished byFF v � OF AR'= Alastb ? " YO US i '4-6 L—Ve C -,IT,� r shPTl C TAMk. Ltd TOWN OF BARNSTABLE LOCATION ,3 SEWAGE # D# 77 VILLAGE QQA'7ZM OGIS 15714 L-57 ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. �tCQ ti C SEPTIC TANK CAPACITY 6�A G C d oO ti LEACHING FACILITY: (type) oZ' � 44CCOW C&AiMsize) �� X ass— NO.OF BEDROOMS . BUILDER OR OWNER C or&e ac co PERMTTDATE: 7-�l ` d/ COMPL CE DATE: O y Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 7. teglfor'1vj on site or within 200 feet of leaching facility). �� Feet?JW Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaphing facility PIA Feet Furnished by $)- SQL ` ? /US F Aq-= k3A 3 t;� ` s C It 133=56pis' A 419 �., 1000 r,g 4 4 odl ►1 s srt-P I C T'/Q.,V/t w 5 � �fr Town of Barnstable �P�pFtHE Regulatory Services Thomas F.Geiler,Director • BA1tNUhl LE. + Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: �UC�l�7T 3�2Gt74- Designer: Installer: e�i1 a Address: . 4 3 V t aE STkEP-r Address: Q v 1 J4 0 233 On_ 7-2$- O Vic I was issued a permit to install a (date) (installer) septic system at 50 t A-VGF—S LA-4 E based on a design drawn by (address) M,�� �2 �•S- dated ? �02_ OX (designer) XJy certify that the septic system referenced above was installed substantially according to the design, which may include minor approved-changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any ponent of the septic system)but in accordance with State&Local Regulations. revision or certified as-built by designer to follow. DA -- � R (Installer's Signature) EYE No. 1140 op4PGISTER�O SAN/7 AN ZA S( -3 (Designer's Signature} (Affix Designer's Stamp Here) U PLEASE RETURN TO BAI STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form . 7Z:l- L0CAT10N SEWAGE ' PERMIT NO. :.VILLAGE INSTALLER'S NAME i ADDRESS r _ d UV,1 1Jn- S� 3�ttJi.s e U I L D E R OR OWNER DATE PERMIT I SUED DATE COMPLIANCE ISSUED � �� �� o. Fxs..... THE COMA OF MASSACHUSETTS .' % BOAR® OF HEALTH ................................--....-...OF....................................... ,Applira#ion for Uiipnstal Works Tonstrnrtinn Prrmit Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal System at Locati ddr ------. !^ - - -n� j2� sal. c��.a�..:� t.N...._. ... _ o nor �-,� , � Add ss � / c.��.o.' ��.Y` . cr�....... - -- Installer Address LL// Type of Building / Size Loi�_7�__��0......Sq. feet Dwelling—No. of Bedrooms---._�....... ........................Expansion Attic (X) Garbage Grinder ( ) Other—Type of Building �To __-._.-.--.. Showers (�) — Cafeteria ( ) d Other fixtures . f persons._..._._. ---- -- ----------------------------------------------------------------•------------•-----------------------•-- W Design Flow........3 ..........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid ca.pacitylom°....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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t ----------- ------------ ---------- ---------------------------- ---- ----------- ---------------------------------------------- O Description of Soil....____..-- L�.. ._G....___ ..................... V ----•----------•----- -------------•----•---------.................--------•---------------------------------------------------------------- •--------------- •--------------- W •••-----------------------------------•••--•--••-------••-•----•---•.-•---=•••--•--•----•-----•---•---------- U Nature of Repairs or Alterationsy'—Answer when applicable............................................................................................... _ �- Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued by the rbdrh / Signed-- • a. e : Application Approved By...- /01 D�J - Application Disapproved for the following seasons:------•-------••-------•--------•---•---------------•---------•-•------...-----•---- Date -•------------------•---=•---...-----•---•--•---.....----•-......---------•-------.............----•-----.....----...----...-•----•-- 8A_ / '7,�— Date Permit No------ 4 --------------•---•----------.......---•--. Issued-............�. '�- D Log =Wmb�r: Bottle # D173 Date: 1.0/1.9/84 :N Of $AR.�. BARNSTABLE COUNTY HEALTH DEPARTMENT SUPERIOR COURT HOUSE V BARNSTABLE, MASSACHUSETTS'02630 Asa DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2511 EXT. 331 Client: George P. Colby Collector: Edward P. Meehan Mailing Address: 21 Studley Rd. Affiliation: Meehan Well Drilling Hyannis, MA 02601 Time & Date of Collection: 10/17/84, 12:00 p.m. Telephone: 775-3272 Type of Supply: well water Sample Location: Lot 57 Lauries Lane Well Depth: 63' Marstons Mills Date of Analysis: 10/18/84 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml , 0 0 - H 5.4 Conductivity (micromhos/cm) 87. 500.0 Iron ( m) 0.05 0.3 Nitrate-Nitrogen ( m) 3.6 10.0 Sodium ( m) -- 20.0 I , xx Water sample meets the recommended limits for drinking of all above tested parameters. II. Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future. monitoring is recommended (2-3 times per year) to establish any upward trends. . B. The low pH of the water may shorten the useful life of the house's plumbing. C. Water may present aesthetic problems (taste, odor, staining) due to D. Water sample has high levels of sodium. Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample is unfit for human consumption: A. High Bacteria B. High Nitrates REMARKS: CC: Barnstable Board of Health CC: Meehan Well Drilling 7/17/84 LaboraYy Director L Expianation'of Test Results Total Coliform Bacteria Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become contaminated from malfunctioning septic systems,cesspools and surface runoff. A total coliform count of zero indicates°that your water supply is safe and approved for human consumption.-A total coliform count'of greater than zero is most often the result of accidental contamination of the sample bottle through improper sampling meihods. For this reason, it would be advisable to retest any well water that is not approved. pH pH is the measure of acidity or alkalinity of the water. On the pH scale, the number 7 is neutral, less than 7 is acidic and more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.0 to 6.5 Conductivity Conductivity is a measure of the dissolved'salts in solution. Amounts in excess of 300 micromhos'-rn are generally considered unacceptable and may have a laxative effect upon users. Iron The presence of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet astringent taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry and porcelain. The average concentration of iron in Cape Cod's water is .2 - .6 ppm. Although the presence of iron in water may cause the problems listed .above, it is not considered deleterious to health. Iron may be removed by .use of an iron removal system. Nitrate-nitrogen The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm. Excessive concentrations may cause methemoglobinemia (an infant disease) and have been suggested to " form potentially carcinogenic nitrosamines. Contamination sources include fertilizers;cesspools and industrial wastes. Copper Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes. This normally does not present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish green stain on porcelain fixtures. Sodium A concentration of sodium over 20 ppm is only of concern to people who are on a tow sodium diet. If the . water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source of drinking water or contact their doctor to determine if consuming the water is advisable. Concentrations exceeding 50 ppm indicate that there may be ocean water or road salt runoff water getting into the well. s No .. t ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................................._OF..................................... . ApplirFation for Disposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct (>�) or Repair ( ) an Individual Sewage Disposal System at: I* ....... �_.��.`�..r 1. . ...... - ..�- • ........... ...................•:�._......_._.�,4.... ....... 1 .��... ,,�.._ A1 TO C Locat' Add or Lot No. caner �' ss t W ` Installer t dd5-ess Z, /.7 U /__Type of Building Size L9.1 .�r'_aa.........Sq. feet Dwelling—No. of Bedro s..... ....................................Expansion Attic ) Garbage Grinder ( ) Other—T e of Buildin �/, ,(� No. of ersons.......2.... a —Type __ _______ __ _ _ _ ( p �,_..___....._. Showers � ) — Cafeteria Other fixtures ....... ) -----------.----------------------------------- ••------........................................ Design Flow.......''-'...............................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitp.R`'......gallons Length................ Width.........:...... Diameter--------.------- Depth................ Disposal Trench—No...........::........ Width..........:.........Total Length.................... Total,leaching area . ft. Seepage Pit No-------------------_ Diameter......,......--..... Depth below inlet.................... Total Teaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by:::..............:......... -------- Date...-.................------••--------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit,................. Depth to ground water........................ P - --------------------�--------------------•---•....----------...•-----....••-----•--•-•----........................................................... D Description of Soil ....... . --•--•----•----------------------------------------•--------------------------------------..........----- �., ---------------------------------------------------------------------------=---------------------------------------------------------------. w UNature of Repairs or Alterations—Answer when applicable------- ,..r-'' ^----------------------------------------------------------_--__------ •---------------------------•-------------------•----------•------------•--....-----.._.........---•------------------------------------------.....--------------------•--------------------•••---•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee �ssued by the b and f he.Ath. - Signed f + ��J�- _. '. _.__..._ Dafe Application Approved By .............. �.6- /.a Application Disapproved for the following reasons:-----•-------------------------------------------------•--------------------•---------------•--•-----••••------ ...................................................:.................................................................................................................................................... Date PermitNo......................................................... Issued--------------------------•--•---•----......••-• ...... Date THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH ..........................................OF.................................................I............................. Tntifirafts of Tompliaanrr �F�IS,,IS TO ERTIFY(,j�That the u' ual Sewage Disposal System constructed,, ) or Repaired ( ) by-•---- `�f (W--- _ _.' '1't_�s!.1.!''t"�'� %f.G�c..................... --_---•- -- ' I ller a � -�'� --f vyr d has been installed in accordance with the provisions of TIME 5 of The State Sanitary Code s desc abed m the application for Disposal Works Construction Permit No......................................... dated......CQ-- .Z - Z!_-.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® A GUA ANT E THAT THE SYSTEM WILL FUNCTION SATISFACTORY. '3 DATE.---•--•-..s�.-/. ................................................... Inspector---------- . . THE COMMONWEALTH OF MASSAC USETTS BOARD OF HEALTH 'cl �......................... FE ;6 ..•--- . Dispo I I arks Tun#r Yrrmit inn Permis ion is hereby granted. 4�......�c,4_� ...... L� f ................................ to Construe( ) or )Repair ( ) an�IInd'v-duall Sewage Disposal System at No!' �.�6------ ---- � ................... creet as shown on the application for Disposal Works Construction Permit 1Vo! 9.??,------ Dated/.94 1`1/- ,------------------ / - _ DATE-------- �' ----•----------•--------------------------••••- Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON P' RIVER ASSESSORS MAP 27 TEST HOLE LOGS NOTES: ,o`' dP�� � � •�*`" $ 1 THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH o �}y, "4(b LOHr �� Pd PARCEL (US y, ) � ��nd ; h,,,�, SOIL EVALUATOR :� .�� HIS FLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE: �I�N N►�;�Pc ��������. ',�� �� BOARD OF HEALTH REGULATIONS. Bch ��ti 4 WITNESS : NOT- HOMES 46-449mo I o� xoHEs ti C REFERENCE: 3LL- (2UZZ DATE:_JUL� ZOD 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, a Ro '' AKERY ���s PERGOLAT I ON RATE: '?A"_►� Gu SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO Apo � J cG ��`I c;0(L �f _C�.7 9 Pd/ v INSTALLATION. o r � a'°�cl` 1( 1 TH- I TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION �'}o mwwe AYx t SPURrWllftrtd ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE ) 1 SA (��/��/ DETERMINATION. A,a J � 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS S: SPECIFIED OTHERWISE) LOAM LOCATION MAP(rl •T -S,) ) � 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A nI GARBAGE DISPOSAL. 1+ 21V� i 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) Nl0 ���LL CoA 3`� MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON V,J 10 1 A BASE OF 6 OF CRUSHED STONE. 7) f lL 7-p tL1�_l.�At PrT _I PGd j Cf-t>S�� _ w �e- Tt`LE V.. ESQN ------- - ---__. .—--- --- E� v o6� �v� FiT SEPTIC S Y S T= E M DSIGN —s `, '- wsu s�o --►tires s rao ►�_ /,N_�sd F --__�kXPA-4F- 6 19E c-ro m-- T6 6&Kn 5y)- ���{; �\ _ �a ltlo W�t�PS wLrJ�sa' dry/�Rdl", 1.��►+_NCt . _ _�___ ___ ---�3 IZ� FLOW ESTIMATE --} -- -� NU NXII ��5 ap TAT? a 0�--1uvv1q p!� ° ) N BEDiOOMS AT GAL/DAY/BEDR00� - � � GAL/DAY P�fLl l �OAIe.� 0r-1(bAt�i 50 \� SEPTIC .TANK Hv vvr.-NoTt C.E �Qv�aEv r-O� -E'��r C6PTI>=l CA -IArJ,- 330 GA'-/DAY. x 2 DAYS - b6D GAL USE 1000 GALLON SEPTIC TANK .��1GSTlIVG` — 1'L-�'�;°�c� �/� � c6� —'`� TI1� t r F'Alt�,) b�A� pf. 24' zs' PH N Tower SOIL A13S9RPT ON SYSTEM T EM ve t, st v' Qi\j Atr..-t..- S r r>E s (Z�, I-x f s w x z U SIDE AREA:FjZS �:4,- i� �rG�2. 0, ILI SGrrc, �' BOTTOM AREA: - Z{0,j U 3 S3.00 G �� � T� �-� SEP f I C' SYSTEM SECT I CAN o vli To j vo, 0� -4i0 J�� CTu 1 13� �� I�> 4� w�r, _4 (0"0-( � s� �YarlP /� 36rM�X P90 qt R k^'t'0 �XiS'rlN Ins�at( 2':.�i820VWet KbSh S �L ASA FFCE',4 CX/S�rnk moo GAL P -bs D-BOX� , I NS 7-9 t,Lt�`1;;.-' '� 1/E P F- �it.��F+Sf \1 j� / \ G7C I sT�r� t t�YA"1r vrJ SEPTIC TANK V'q L) k �' lCrnl�� ) "'� -( � / -�, 5n b _. 8s DKI'vL A55uM 7Tb Le G L`, eO, 05 (��v1 �HOFrq�sS�c , SITE AND SEWAGE PLAN DAR '�\ o LOCATION : ` No. I .� k r.s�NIT PREPARED FOR • coLE>�� L�� (0 ; . 0��� SCALE: / 0 r �v DARREN M. MEYER, R.S. DATE: 7/Z-d a 43VNE STREET ---`� 3 Dvl E HEA4-TH AGENT (7 1) 85-0293 w t •✓oTe- �, /ocat,'0, Shocur, ar e - C � O 7� Jr(�) \ ProPoSGd orr/cJ oiaturn /s M. S.L. ✓R �q . Z 3 .g �:, 3 z '� • - t=I. .k#c4a- _. W Th/ 00 o • �Q' � � � � v IMF (bp __ I, vy. S`E• �/.�9 G G y0 U T" 0,,-9 77,19 - T& S 7T ti 0 L 6 �e C—S UL TS ILL- 0AO%l j9pa5 45Aj /N✓EST Ee- V,197-/0N45 dote `f 2' -7? SuPei-visGd bc'. ' 3 $ ErG� �°1OOMS /000 c�a/. SG�fiG f'ar�� cJ0/-/N �E�.LEY" G �.•�CH /E'ATE `— Z- rrrir�./inch ovt/et a/e% 9s'oo - S4 / �oa. � £ SL/65oi� oopoeoF�OSE� LE/4eH /a/E�E/q �istributiorr bvX ��'�/r - /44 = G/ears rr7eo� Sct �c/ _... 'g-S S•,f' ram/ 9 a//o/a.y i n/s t a/e✓ -�r .__ %,�7b' r/o l.�u. f e r e/-7 c 0 u 1-7 ir-79 x,4'Gs/7Si0,17 — �/ ) G �o%ofh� �c,rGc.asf Pere. r'czfe /each pit /irred w-th z ' �"rrr,n� of wasi,ed stor^;E• irr 1 t f- C/e✓. elm s / ,. z �m/�) foyer o,f I �fi-- Pitch ioQr ,foot -� S �easfor�e /yel %each •• LL�/h � a S f'O I^7 e ° ♦ o • • 1 M • lot ♦ D , y"hs rG9istcsreo/ Grp/rr a er t.✓f'roSG 9A. OF L.ANv /A./25 S?fu �n�o Glia�ears Or7 theSC c�rGt wir�r�S shc�.// be �-esPor�Sib/e_ ,for tire. �A/S 7T� 8 � � �/YJfI�eSTo/vS /1/l� S S /M/LCS > sc��sr✓ision ur�o/ certificatior� of ,{oI" : /t/fDO -' ��G f-� /y0/1/f S IAJC Gnr�struc tior� ire strict- c+ ccordarrc e SC��O ; �� with these /ans cuhtn a ro✓eo/ b � = 30 daL tG : F�!JGUS7" /�j77 P fP y -t/ie 1Po✓Crr,ir79 bOCLro/ of heMAYL/7. Gcj•9/c--' C— e3 � S 77,99 T E S BOfl/2O Of HEfi G. Tly 1 C-E�-T Ft( -r"4xT -r-aE �1 M�E:- Q F:- TH C UP-1 v E>(. Of P•_ JAMES :. coo�♦ctr-� C cz�G G r�9 i r�e c ri r7 �,►Aw► 9 ,:,pit. No. 3079t 4r L AitJO Sure v�yOOe S �Fss�; � �S�ONAL , oust iA�.- y°q�Mou7-N, MASS. 1_ li.. {yam►, �..yy��� .. - -o..zl�!+��i S.a, .;4"Y�'`r;� °F� ,•,.v. • _ err . . - __ _ i�S'M V f a t,