HomeMy WebLinkAbout0060 SMOKE VALLEY ROAD - Health 60 Sm ikey Valley Road ;.
94ai stons�Mills =-
K
A=..097„,i 024 t,
oa L
Commonwealth of Massachusetts
�r p Title 5 Official Inspection Form
iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Smoke Valley Rd
u Property Address '
Paul Merlesena
Owner Owner's Name 4
information is required for every Osteryille Ma. 02644 9-15-20
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
filling out forms
on the computer, Michael Sears
use only the tab
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key. ,
363 Whites Path
Company Address
South Yarmouth Ma. 02664
AA City/Town State Zip Code
r�n 508-477-8877 S114430
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
`` P�SN OF�M,gss
�
2. ❑ Conditionally Passes q;���y� .• • oy
M I C H A E L '.N
3. ❑ Needs Further Evaluation by the Local Approving Authority = SEARS M'
No.SI14430 �'a
4. ❑ Fails , �' of �o.•
9-15-20
Inspector's Sign re 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
�n Title 5 Official Inspection Form
lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Smoke Valley Rd
V�
Property Address
Paul Merlesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
State Zip Code Date of Inspection
page. Cityrrown
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
�n ,tip Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
u—
60 Smoke Valley Rd
Property Address
Paul Merilesena
Owner Owner's Name
information is required for every Osterville Ma. 02644 9-15-20
page. City/Town 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 pipes) are replaced ❑ Y ❑ N ElND (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
,p Title 5 Official Inspection Form
�0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
60 Smoke Valley Rd
Property Address
Paul Medesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
page. City/Town 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:
**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 ® 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
w ,` Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.......... 60 Smoke Valley Rd
u
Property Address
Paul Merlesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
page. City/Town 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.
❑ ® 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
lop.,
Commonwealth of Massachusetts
_ 1p Title 5 Official Inspection Form
i1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I;
60 Smoke Valley Rd
u� Property Address
Paul McAesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
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 aH inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
I
® ❑ 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.
❑ Z 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
Tripp,Vanessa
From: Lindsay Montgomery <LMontgomery@robertbour.com>
Sent: Thursday, September 17, 2020 2AS PM
To: Tripp,Vanessa
Subject: 60 Smoke Valley Road, Osterville
Attachments: 20200917144251355.pdf
Hi Vanessa
I mailed a title 5 septic inspection yesterday for 60 Smoke Valley Road, Osterville.
I guess the homeowner was incorrect on the number of bedrooms in the house.
Can you please update this report with the attached page when you receive it?
Thank you!
Li wdsau Moo-tgovv erlu
Robert B. Our Co., Inc
363 Whites Path, South Yarmouth, Ma 02664 i 5o8-477-8877
�1tITYaxQ
Btan trust
CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open
attachments or reply, unless you recognize the sender's email address and know the content is safe!
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Smoke Valley Rd.
Property Address
Paul Meriesena
Owner Owner's Name _
information is Osterville Ma. 02644 9-15-20
required for every — — - ----
page. Clty/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms(actual): 5---
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 _
Description:
Number of current residents: NA
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 ears usage d 2018-73000 gal
g ( y g (gp )) 2019-63000 gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: p e
l5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
60 Smoke Valley Rd
Property Address
Paul Mer+esena
Owner Owner's Name
.information is Osterville Ma. 02644 9-15-20
required for every
page. Cityrrown State Zip Code Date of Inspection
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:
Source of information: 10-18-2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... !% 60 Smoke Valley Rd
Property Address
Paul Merlesena
Owner Owner's Name
information is required for every Osterville Ma. 02644 9-15-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
75"
Depth below grade: feet
Material of construction: ,
❑ cast iron ® 40 PVC ❑ other(explain):
..Distance from private water supply well or suction line. feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
S
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
60 Smoke Valley Rd
Property Address
Paul Merlesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
65"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No,
'
Dimensions: 1500 gal
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
24"
2
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge judge tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gal tank with both covers at 22" below grade in and out tees in place
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
< Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
li; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Smoke Valley Rd -
Property Address
Paul Meriesena
Owner Owner's Name
information is required for every Cisterville Ma. 02644 9-15-20
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
l5insp.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
f- 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
60 Smoke Valley Rd
Property Address
Paul Medesena
Owner Owner's Name
information is required for every osteryllle Ma. 02644 9-15-20
page. City/Town 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.):
D Box is H2O 32x32 with 2 outlet pipes box is at T with cover at 22" below grade
I
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
60 Smoke Valley Rd
Property Address
Paul McAesena
Owner Owner's Name
information is Osteryllle Ma. 02644 9-15-20
required for every
State Zip Code Date of Inspection
page. City/Town
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:
p Y
Type.
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
I
Type/name of technology:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
60 Smoke Valley Rd
Property Address
Paul Merllesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
page. City/Town 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.):
SAS is 2- 1000 gal pit pits at 7' with covers at 22" below grade no sign of failure
/
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
c , Commonwealth of Massachusetts.
Title 5 Official Inspection Form
�- I1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 60 Smoke Valley Rd
Property Address
Paul Merjesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
page. Cityfrown 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
60 Smoke Valley Rd
u� Property Address
Paul McAesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every —
State Zip Code Date of Inspection
page. City/Town
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
A B
a -33
3_38.:�
p
5_Sy.N
6 OJ3
3 31-/
.3
��N OF 1Mgss
MICHAEL gym=
o SEARS
No.SI14430
INS?-
m?-
Disposal S stem•Page 16 of 18
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewagep Y
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
I1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 60 Smoke Valley Rd
Property Address
Paul Merlesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
12'+
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: 2-6-84
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
No ground water per plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
<iI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 60 Smoke Valley Rd
Property Address
Paul McAesena
Owner Owner's Name
information is Osterville Ma. 02644 9-15-20
required for every
page. Cityrrown 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 4 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
9/14/2020 ShowAsbuilt(1700x2800)
FR
LOCATION /7 SEWAGE PERMIT NO.
poi ., v��r/Ac�=yin YY-BAG
41L1 GE
LB
INSTALLER'S NAME A ADDRESS
a IUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE 1'S5UED /p-`tBY
Jti�LJ ONy
n
https://itsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuiIt?mp=097024&sq=1 1/1
TOWN OF BARNSTABLE
LOCATION (®® Sl 0YG VA(-L&-y SEWAGE# 3
VILLAGE OSTCRW44(f. ASSESSOR'S MAP&PARCEL OZi ®;Xc '
INSTALLER'S NAME&PHONE NO.CA SLAJ 0E ®UP, 609-1417-22-77
SEPTIC TANK CAPACITY 15tc0 a,464.O&D
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
OWNER P.4c'L— M�5EAJA D-�®
PERMIT DATE: COMPLIANCE DATE: 01—(o a oao tl
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) w— Feet
FURNISHED BY ( MF-w i NE E& � �
A-i 21.(P° S-►: oAS.
e �
OR33` a-3 -M& _
smu
A-s= GIs' 11-5'
0 3
y
No. cie 2 -- 03 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplifation for Disposal 6pstem Construction 3permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No. (� $eetip jig IJi¢Ll.�z{ 7�b Owner's Name,Address,and Tel.No.
,/ PAuc. NtERI�xNd
Assessor's Map/Parcel 097 �Y (ov 50c0w-is iL4 R-'b .0 ST-
Installer's Name,Address,and Tel.No. 5pg-+77-2$'7? Designer's Name,Address,and Tel.No.
<ZA' �yWeD6, 45�514A156$
53 l
Type of Building:
Dwelling No.of Bedrooms Lot Size r>P000 sq.ft. Garbage Grinder( )
Other Type of Building R&SID61C;'l o4-(- No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) T SLWLL= A.&;9{,) fT.X: 5
L•Rll./�+C---
jk:�W 6-60,k--
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He
<, S e Date id
Application Approved by Date C7-
Application Disapproved by Date
for the following reasons
.. F
Permit No. '� 012 Date Issued
� 1
No; 03 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppflcation.for Voposal 4pstem Construction Permit
Application for a Permit to Construct( ) Repair(4 Upgrade(r) Abandon( ) [:]Complete System �dividual Components
Location Address or Lot No. 6,0 suc p4ge, 0,o((,4j=--{ Itb Owner's Name,Address,and Tel.No.
6
Assessor's Map/Parcel 097 C;t T ' Go %ze 4:4 b dS`r
Installer's Name,Address,and Tel.No. W Af'71-n T 7 Designer's Name,Address,and Tel.No.
Su_)6-w w& 5-i OEM 1
Type of Building: 14
Dwelling No.of Bedrooms Lot Size d}.Z�l20c) q.ft. Garbage Grinder( )
Other Type of Building P.&_S/D6V_jFl AJ_.- No.of Persons Showers( ) Cafeteria( ).
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
F'
Description of Soil
d
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
f� Agreement:
The undersigned'agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
f Compliance has been issued by this Board of He4tli
Si ned Date �� w a®17,
Application Approved by r '" "f":""^"�I, l .Date
Application Disapproved by Date
for the following reasons
Permit No. �'��/ "' 3 ~a' Date Issued a-
THE COMMONWEALTH OF MASSACHUSETTS
1 d!-�� �` BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(A) Upgraded( )
Abandoned( )by CA?stv
at 4,0 5 cctc-,40�, VALL4_" has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NQP/7—Q 3aated / �?
Installer OW&CO rb�_- aomakg&E7 Designer
#bedrooms II\�I .� Approved design flow gpd
The issuance of this permit hall not be construed as a guarantee that the system will � t/io,as�es gned. n
Date Inspector
No. —D 3 b Fee 2 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
is osal 6pstem Construction Vermit
Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( )
System located at -541 dy [J/¢{��Z ^`^j
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be co leted within three years of the date of this perm" it.
Date /�} Approved b
Commonwealth of Massachusetts P1�� U�
1 �
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
3>
60 Smoke Valley Road
wo'. -
Property Address
Paul Meriesena
Owner Owner's Name
information is as
required for every 99teftift M ars+V)5 M MI s MA 02655
2-22-17
page. City/Town a-�
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. General Information
filling out forms �� - / �Uuulltlllrquii
on the computer, 1a/5
use only the tab 1. Ins eCtOr: ````������,�F1 OF�S ii,,��''
key to move your p ��,. ••`. �+y
S.
cursor-do not James DSears = ,' JAMES N,=
use the return .
key. Name of Inspector -
- :mom
Ca ewide Enter rises
Company Name
153 Commercial Street °��� �5 INSO-C�01`\NN
Company Address ern tpa
A Mashpee MA 02649
C itytTown State
508-477-8877 Zip Code
S1623
Telephone Number
License Number
B. Certification
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 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2-22-17
pectors Signature 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This Inspection does not address how the system will perform in the future under
the same or different conditions of use.
15ins.doc•rev.6116
Title 5 Official Inspection Form:Subaurlace Sewage Disposal System•Page 1 of 17
4o�� vs
6l abed 6666t£S80S uew jol�adsui ayl wlr 99:02 L60Z 9Z 9aj
<L'\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Dwner's Name
information is OSterville
required for every MA 02655 2-22-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 16.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal. Tank H- 20 D Box and two pits
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old'or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
I
t5ins.doc•rev.6116
Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 2 of V
02 a5ed 66661VES909 ueW imoadsul ayl wlr 950Z LI.OZ 9E qaj
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is
required for every Osterville MA 02655 2-22-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cant.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below);
❑ obstruction is removed ❑ Y ❑ N ❑ 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):
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
t5ins.doa•rev.6116
TIUS 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
6Z a5ed M6t£5805 ueW uoioadsul ayl wlj 95;OZ L60Z 9Z qaj
<C*\, Commonwealth of Massachusetts
19Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.�-I60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
Information is
required fir every Osterville MA 02655 2-22-17
page. Cityf7own State Zip Code Date of Inspection
B. Certification (cost.)
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 9 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in MOM=is less than 6" below invert or available volume is less
than Yz day flow P r�+
tslns.doc-rev.&1e
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
ZZ a5ed 61.66VE5809 ueW jo3Dadsul auL wir 99:2 L602 9Z qaj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is
required for every Osterville MA 02655 2-22-17
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes If the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fak.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
f questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15ina.doc•rev.6N6
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page s o1 17
£Z afied 61.66tr£5805 ueW uo}cadsui ayl wir LS;OZ L 60Z 92 9aj
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is required for every Osterville MA 02655 2-22-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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?
1:1 ® Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System,(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 god x#of bedrooms): 550
I5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsusfaae Sewage Disposal System-Page 6 or 17
t,Z abed 6 666b£9809 ueW jolmdsui aLLL wir 29:02 L 60Z 92 qaj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 60 Smoke Valley Road
Property Address
Paul Meriesena
Corner Owner's Name
information is OStefVllle
required for every MA 02655 2-22-17
page. CitylTown State Zip Code Dale of Inspection
D. System Information
Description:
The system is a 1500 Gal. Tank H-20 D Box and two pits.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203
) Gallons per day(gpd)
Basis of design flow(seatslpersons/sq.ft, etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins.doo•rev.6r16
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
q2 96ed 6666VE9809 ueW uoiDadsul a4i wig 9g:02 L602 92 9aj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a`
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is
required for every Osterville MA 02655
page. City/Town 2-22-17
State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occu pancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of system:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous in
spection ns action records 'P , 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 contrac
t
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
15lns.00c•rev,6/I6
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 6 of 17
9Z abed 61.66bE5805 ueW uo3Dadsui ayl wig 8502 L 60Z 92 qaj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
informationis
required
wir for for every QSteryille MA 02655 2-22-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Pits 84-866 New Tank and D Box 2-2017.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 71
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 6'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ Polyethylene
❑other(explain)
"r
If tank is metal, list age:
years
• Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal.Precast H-20
Sludge depth: 0"
151 na.dac•rev.6116
Tllle 5 official Inspection Form:Subsurtacs Sewage Disposal Syslem•Page 9 of 17
LZ abed 6 666t£9809 UeW imoadsui ayl wig 69:02 L 60Z 9Z 9aj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is
required for every Osterville MA 02655
page. City/Town 2-22-17
State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 301,
Scum thickness 0"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? 2-2017 New Tank
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 new 2-2017. In and outlet Tee's wlboth covers at 8" below grade,
Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑metal fiberglass g ❑ 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
15ins.doc•rev.6/16
Titre 5Official inspectlon Form:Subsurface Sewage Disposal System•page 10 of 17
8Z a5ed 6666KS80S ueW uoquadsui ayl wlr 6S:02 L1,2 9Z qaj
Commonwealth of Massachusetts
Lip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is
required for every Osterville MA 02655 2-22-17
page. City/Town State Zip Code Date of Inspection '
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass g El polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
16ins.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 11 of 17
6E a6ed 61.66VE9809 ueW uoQ:)adsui ayl wif 69:2 Z I.OZ 9Z qa�j
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is required for every Osterville MA 02655 2-22-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
2-2017 New D Box H-20 at 6'-6" below grade. W/cover at 8"_Two line's out
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins.doc rev.W16 TNIe S Offfclal Inspection Form:Subsurface Sewage Disposal System-Pape 12 of 17
0£ a5ed 6166b£9809 uew joloadsui atL wig 00:62 L 60Z 9Z qaj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Smoke Valley Road
Property Addrass
Paul Meriesena
Owner Owner's Name
information is required for every OSterville . MA 02656 2-22-17
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
I
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leachingfields
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.):
Leaching is two 1000 Gal. precast pit's w/2' stone. Pit's with wet bottom's w/stain li nes at 2'-K No
sign of over loading.
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
I
Indication of groundwater inflow ❑ Yes ❑ No
�hs.��•rev.r�,e
Title 5 Oftlal Inspection Form:subsurtaoe Sewage Disposal System.Page 13 of 17
�£ a5ed 66661V£9809 ueW joloadsul ayl wir 00:6Z L60Z 9Z qaj
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Smoke Valley Road
Property Wddress
Paul Meriesena
Owner Owner's Name
information is OSterville
required for every MA 02655 2-22-17
page, Cdyfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation-
etc,):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
ISins.doc•rev.6116
Title 6 Official Inspection Form:Subsurface Sewage Oisposel System-Page 14 of 17
Z£ abed 6I.66t£9809 ueW J013adsui aU wlr 00:2 L 1,0e R qaj
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
Information is
required for every Osterville MA 02655 2-22-17
page. Cityrrown State Zip Code
Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
N'
A 13
-PAQ
o
0
t5ins.tloc•rev.6n 6
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 15 of 17
££ a5ed 61.66bE5805 ueW -ioloadsul ayl wlr 00:6Z L 60Z gZ qaj
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information Is
required for every Osterville MA 02655 2-22-17
page. cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam.-
El Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells Ne
Estimated depth to high ground water 12'+
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: 2-6-84
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 2-6-84 no G W at 12'+ high area No sign of G W problem
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins,doo-rev.6116
Title 5 Official Inspection Form:Subsurface Sewage Disposal Systam•rage 16 or 17
t,E a5ed 6 666t ESSOS uew JmDadsui ayl wir 60:1•Z L IOZ gZ qaj
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
60 Smoke Valley Road
Property Address
Paul Meriesena
Owner Owner's Name
information is
required for every Osterville MA 02655 2-22_1 7
page. Cityrrown Slate Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6115
TIde 5 Official Inspeciio-i Form:Subsurface Sewage oisposal System Page 17 of 17
S£ abed 61,66b£5805 ueW joiDadsui ayl wlr 60 6Z L l•0Z 9Z qaj
Fee---------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
0(pplication-*rVer[ Comgtruttionpermit
Application is hereby m de for a permit to Constr c (d), Alter ( ), or Repair ( )an individual Well at:
Locatid"n — Address 1 Assessors Map and Parcel —
� •�� lM e(/�S i r'G—---- ---- --------- _ W (D V /? — -- -----
Owner Address
/= --------------- �� -----
Installer — Driller �— Address
Type of Building
Dwelling--------------------------------------------------------------
Other - Type of Building------------------------------- No. of Persons--------------------------------------------
Type of Well - -- - ------- Capacity------------------ -
-----------------------------------
Purpose of Well---t/��c�_�f Le�---------— --- ---
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
// - --
Signed-1 - --------------------- -----�_.I f�
date
Application Approved By
date
Application Disapproved for the following reasons:---------------------------------------------------------------------
--------------------------- ---
----- ---------
��/ date
Permit No. --�� '� . —-- —-- Issued---z -�---='--- - - ----------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifitate ®f Compliance
THIS IS TO CERTIFY, Th the I dividual Well Constructed ( �, Altered ( ), or Repaired ( )
by----------------�-��-"4-- ---
-------
-------------------------------------------------------------- -------------------------
/ --
Installer
--------------
at- O S6'10 1 CC Uc,�G? - _(��_�—D_ 1�s_v r( -- —-`-s--------------------------------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit Noll-` g'''!?--=- Dated---b --��
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- --- ------- — - - - -- Inspector----------------------------------------—- - ------------
.� No.- _ ----- Fee---------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
0[ppCication forVe[C Con0ruct ion A3ermit
Application is hereby made for a permit to Construct (✓), Alter ( ), or Repair ( )an individual Well at:
- D
jj
f -- --—-- .. T-T y--� -
Location — Address Assessors ap and Parcel
�� h_,M - = '--- --- —- -��=---s, ...........
c'ti' Gd- - -- -
-Owner / ddress
R-- -------—----
Installer — Driller Address
Type of Building
Dwelling-------—------------------------------------------------------
Other - Type of Building ------ No. of Persons------------------------------___—_____________
I ��` ----- Capacity
! , Type of We11=----!----;�------------------------------------- --------------=------- ------- --
-- - -- ----------------------
Purpose of Well '/-ifives---------------------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
Signed
- -- --------
date
Application Approved B
PP PP rove Y -.
date 1 .
Application Disapproved for the following reasons:-------- --------------------------
--------------------------- -- --
Permit No. -- ="jv—' _-- —_ — Issued = — —--—date-----------
— ---
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
.. Certificate Of Compliance
THIS IS TO CERTIFY, Thar the IrAividual Well Constructed ( .Uj, Altered ( ), or Repaired ( )
bY------------------J)-ZA_----- — - —- -------------------------------------------------------------------------------
----
--------------------------
Installer
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit Nol���--6�---' eOD-ated--go''_-`--�'-���
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------—- — -- -- ------ Inspector--------------------------------------------- - ------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Uhl[ Cootruction3permit
No. �- Fee,
Permission is hereby granted--1�- �
to Construct ( c-, Alter ( ), or Repair ( ) an Individual Well at:
No. --4jnL-S"-fZr Jc1rn -----—-------------- «ee------------------- -
s
as shown o the application
No. .___________ 11 Construction Permit
/n ` for a We
J��+�_, �'" `�' ' —-- —- — - Dated-— - `� ! — ---------------------------------------
'/
DATE - Board of Health
----- �_ — —`�
LOCATION SEWAGE PERMIT NAP:
. 10�OLAL GE
IN-STA LLER'S NAME i ADDRESS
BUILDER OR OWNER
�)I s
DATE PERMIT ISSUED
DATE COMPLIANCE -ISSUED '
w
��� ._ �, �� • � r of
} �� /3 Z�
No.......�i�.J:.���' ., Fx$............�_>. _....
yf'H$ COMMON0 ACTH OF MASSACHUSETTS --
" BOARD OF HEALTH
-----------------O F...W/1.......4TAft..C,&............................................
Appliration- for Disposal Works Tonstrurtion rrmi
Application is hereby made for a Permit to Construct ( or Repair ( )' an Individual Sewage Disposal
system at:
.....6!!1Q.1. ..L1.�4. :` ..- - w �..�:'..' ..................•---------......•to T. ".`- ....._.......................--•--•-
Location-Address - or Lot N
294V(.�.....k.�._..t.Y ._ A.............•....... •--•...s�..Y... ... e....... 9
._.�:e...----�a:���::...........---...----
..
Owner ..
. Address
. ?. T4
i�. . = -
. . ..
Installer '' Address
Type of Building a �� Size Lot................:...........Sq. feet
U Dwelling—No. of Bedrooms...............jc ..........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............. No. of persons..............._............ Showers , — Cafeteria.
a+ Other fixtures ................ .
-•------.......... -•••••..............._�.................................
W . Design Flo*......5__'7--------------------------gallons per.person per day. Total daily-------------------
flow..........
WSeptic Tank—Liquid'capacity/. allons Length.l• -�__•. Width....4.'�... Diameter-------- ...... Depth••K-�`�
xDisposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......2.......... Diameter....../d...... Depth below inlet......Ge........: Total leaching area.../,-" v-.sq. ft.
Z Other Distribution box ( ) , Dosing tank
Percolation Test Results Performed by....4.,Q4.G-a,_-J......c; G•:.cam. -----•' Date..... 1.41 .`/......0.4
Test Pit No.' l.....9�-'Fninutes per inch Depth of Test Pit..:- _y`l`Depth to ground water....e %.Z....-.:
Test Pit No. 2................minutes per inch, 'Depth of Test Pit.................... Depth to ground water........................
• t
p,+ =--- -•--.---•-.-•---`---•----------- ----------------------------------------=---------------•.........................
Description of Soil._.._.C? i_y...... _..r`,.� ...•......------ --
V ............NO.=....!C�... .................•---.....---•--.............-----...........-------•--........-----•------ ....... ---------------------•---------=
W ..--------•----••------•_•-------•---•------•---•----•--•-----•-------•--•=---•-••-•-----------------------•-•-----•----....-•-•-•----•-------------•------•--•----........--•--•-•-•--...-------
UNature of Repairs or Alterations—Answer when applicable..................................................................:.........................
Agreement
The indersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI7PLZ 5 of the State Sanitar —The undersigned further agrees not to.place the system in
operation until a Certificate of Compliance h s b en iss ed by oard of health.'
•
g
Si Signed... ..............
Date
4
Application Approved By--••---•.............. . . ..:.. .r.........../ t�.:/1 •
- ••. ••• -•---•......---•-----••-
J. Date
Application Disapproved for the following reasons------------------•---.....------........----•-......---------=---...-----------------.............--........----
....--•----•.........................•---•-••-••----.........----••••--•-....---•---•--•--•--......:_.._......•--••----...::......-----•----•-----••---•---•--------------•••-•-•--••••--••-----..._.....
Date
Permit No......................................................... Issued----------------•-----•-•....._
- Date .......-•-----•-••.•
No- - :.Dt22j? ` �' FEE..............
^ tHE COMMON"21F, OF MASSACHUSETTS---
y' BOARD OF HEALTH
r Appliration for Disposal Works Tonst,rurtion Vami#
�Ijo Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal
System at: �'j`�: S M/�/s
.........21�;��. C�`....�/.�:'f.��.L.•L:� ri� .._...�7_cJ/G_GCc:. .................... ...................................
Location-Address or Lot No.
''........................... a�=a� r� `�—�-....... li%l a41: ...........................
Owner Address
a �l ,......T ............ A �2 4_��............ •- t .! A.=a._ ...�5,:....... .in.
-� -
Installer Address
Type'of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms..............l:r.......................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building p, YP g No. of persons--------------------------- Showers ( ) — Cafeteria ( )
04 Other fixtures .........--••--•--------------------------------------.•-_
d ---------- --- ---- --•-------
WW Design Flow......._�":.....:...:................gallons per person per day. Total daily flow_._-.._,_� __._...-...._......gallons.
WSeptic Tank—Liquid capacity/.�ixZallons Length../?--_----- Width..... Diameter................ Depth__,�_;..a...`.:
x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No....... Diameter.....-,:'-2-.`.. Depth below inlet......__........... Total leaching area... ft.
Z
Other Distribution box ( ) Dosing tank ( )
`� !) « : :.?!r.--:..�d�.�.,..... D'ate _ r=-• f.fl.....
a Percolation Test Results Performed by..__ .�
Test Pit No. 1--•-_ir"'-minutes per inch Depth of Test Pit..... Depth to ground water...........Z?.....
Gr. Test Pit No. 2:...............minufes per inch Depth of Test Pit.................... Depth to ground water...............t'�-.___:
N ----•----•--------------------------• -•----•-•---•.._....••........_..............---.........._...---..........--•----------------------------------_-----
DDescription of Soil ' ?.51.__`_......... :_` ..: `�-' �'c t� ` nrr'{.p` (�. /-' -------------•_.R.:._.._ __ .C�._. _ _.�• _._Y.._________L_=.S.,�R;..yS-r---:-�.5/
V .........•..A _ ....... ..........................................................------............-
` ........................................................ .•--•----•--••--•-•---..........._.......----•----•-•-•-----•--•--•----•-•---••--------.--••---------•----------........_......._..............
fU Nature of Repairs or Alterations—Answer when applicable..............................................................................................
j Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance'with
the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance his f en 1 sued by�t -board of health.
Signed- l _ -a. ....................
Date
Application Approved BY .__... � � _...... . �.. .111_-r!r:.19............
Date.
Application Disapproved for the following reasons:........... -•-•--•-•••-•----•••.....------••• = l-••-------=•••-•--•...............•-----.._...--•-
k ....................................................................................................................................... .._._. .
�._p_- ,............................- —
.._._
. ... ""-...9. Date
PermitNo....................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Irrfifirgtr of TOttt�rlittnr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
b /i�+•^:_ .........A---�__---__--_��A._e-2 :1ir_..� ?.�::.'..:::'...........................................................................................................
Installer
at..........4-i .......... C>...------- ----- -------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describe' in the
application for Disposal Works Construction Permiti;Nb._'?I^. ............ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
...
'
DATE..............................;t-- � i --•---•• Inspector......
—— ____-- __........_._,..._..___
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.�l .1...... ......:....................................OF.....................................................................................
. _...__. � FEE.._✓-•. .............
Disposal Works TOnsirnrfion f rrmi#
Permission is hereby granted....... _ ••-----" •=... S .... ................--- .............................
to Construct ( ),or.-Repair ( ) an Individual Sewage Disposal System `•
at No...... •-n- � ---• ._ �a/!i•-.�-. J a'P��z... /r1'7:• �-� r_r_c._�,............... ----------z. -•-
Street
as shown on the application for Disposal Works Construction Permit No.:Rq::!R(a62 Dated----- ...........'...
..J__ ..
Board of Health �.
DATE................................................................................. �.
�4u :
-`7 —7- 7 77—,
e, -r,.— vlmw
77� 7
Y,'77t.
I M-
n 5""-07
let I I visit AT--, M
AM;
Top
t7
Alto
A— 77 ylmt now
n"X
W"-
'4F n�vl r-ov r
: -Novo 1
CP
lot
SL
1A)AS e
M pv a Ash 01007
L V
Flo
'40
4/71/
14
i/7 V. 46
0 C I1c W , , IT
......... 40
/7
OVA-..�A Intj, '
-OL S .17
7 E /117
p ota"
(001i
Sol
A"4
Zvi �jo
how
0
nil
Is -7- a slow's 4ki
0 77/M A-ra-0
oil 1 .17
W 0 Am d!0 ��q Aj
o
Dtq
^4
U
7-1 C .'-r;q elA PA C I T*7-
C)L IV07,
r 6
_W41
_,v I �" r-7
4 1AJ G `;-C A
4� C
Ir= 4c
H
77
:77
A/0,717z=
4Q r&
40"1=OR M
4(
AJ oO
Ono.4q io"L S /�4q
oj4e
Aj 7
54 AJ�S
e a, U L49 rl b
7*OA=-
--ski 4
ID
- , , ' S 5 E
ion 1 L
'0 C-'�q 7
1,011 Vol
...... -------
49 7_
ell
7.�
UF
S jL our
too
little,v
WTER&
117. C 40�7.
Ail
A J
0
-oak not
oil A
Zoo,