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HomeMy WebLinkAbout0029 THATCHER HOLWAY ROAD UNIT #A - Health 29 Thatcher Ho4la R®ed Mars(ons Mills IR � A - 1.48 084 i i jl I �14 f /y8_08� Commonwealth of Massachusetts �n F Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 29 Thatcher Holway Rd Property Address '' t Leite s Owner Owner's Name information is required for every Marstons Mills ✓ Ma 02648 9/17/19 page: City/Town State Zip Code Date of Inspection r � 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 filling out forms A. Inspector Informationj. .�' f it( on the computer, use only the tab Chad hathaway ` key to move your Name of Inspector cursor-do not HPS use the return key. Company Name � Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 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 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/17/19 spectoe Si ture Date The system inspector sha ubmit .eopy of this inspection report to the Approving Authority(Board of Health or DEP)withi 0 d of completing this inspection. If the system has a design flow of 10,000 gpd or greater, 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. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts ,q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 " page. City./town 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: ® 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass. ov 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 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.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 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 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 ❑ ® 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 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owners Name information is required for every Marstons Mills Ma 02648 9/17/19 page. Cityfrown 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.7/2 612 01 8 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 page. City/Town 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 ❑ ® 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) 0 ❑ 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 I Commonwealth of Massachusetts �. ,p Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 page. City(rown 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): 330 Description: 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)): Detail: 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 Commonwealth of Massachusetts lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 page. CitylTown 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: pumps every 2-3 years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 page. Cityrrown 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: 2005 leaching and Dbox tank on anal Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ See asbuilt feet Comments(on condition of joints, venting, evidence of leakage, etc.): 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is Marstons Mills Ma 02648 9/17/19 required for every i page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal H10 with risers If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x5' Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness less then 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place. risers in place. no visable decay or leaks. pump tank every 2 years under normal usage t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 page. City/Town 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 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 4 ,» 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is Marstons Mills Ma 02648 9/17/19 required for every page. Cityrrown 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 clear of carry overs no heavy decay or visable leaks riser in place t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Sub surface Sewage Disposal System Form Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 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: Type: ❑ leaching pits number: ® leaching chambers number: 5 Hi cap infultrators ❑ 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 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.): 36'x11'x10" per asbuilt. inspection port opened and SAS was dry. cap 2" below grade 4" pvc inspection port 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owners Name information is required for every Marstons Mills Ma 02648 9/17/19 page. CityrFown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is Marstons Mills Ma 02648 9/17/19 required for every page. Citylrown 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 gcck a-r4ue • rt �) G � ,cam a o � 0 O e I C 0 U ado�, o0 iro 0 ° o co" q � 3 - 33 , � 3 3c/ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts rn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: town GIS mapping lot el. 58 You must describe how you established the high ground water elevation: low in area el. 30 wetlands + pond estimated depth to G/W 28' bottom of SAS at 5' , 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 I Commonwealth of Massachusetts r Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Thatcher Holway Rd Property Address Leite Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/17/19 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. Z 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 Health Department Drop-Off Hours: 8:00 AM —4:30 P.M Town of Barnstable Received by Health opVEr Regulatory Services Department on IARNSfAB[.E, Richard V.Scali,Director + � 9� s ,�r Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE Property Address: �OCG l P L/ Assessors Map/Parcel Number: 17 Applicant(s) Name: Je(1 (��. CA 4) Phone: �7-3619 oZ Li' 3 9 E-Mail: J r5 or Pr�n��'�1 of Lot: o l q J D L Ge- Size 2a. How many bedrooms exist at your property now? 2b. How many bedroom are you planning to add as part of the Accessory Affordable Apartment Program application? e r I (� e 2c. How many bedrooms total are proposed at this property (including the Accessory unit)? 2e. Is!�tmain ed Accessory Apartment contained within: house; OR a.detached structure 2f. Submit floor plans for all buildings on the entire property. Show all existing rooms in the dwelling and the proposed accessory apartment. Label each room clearly. Label measured width of all open doorways. Use straight edge for hand drawn plans and be sure all labeling is legible. Signed: Date: �� l 1 s ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE FOR STAFF,USE ONLY 1. Is the dwelling connected to Town sewer? ❑ Yes ZN 2. Dwelling located INSIDE ❑ OUTSIDE the Saltwater Estuary Protection Zone 3. Dwelling located C 'INSIDE ❑ OUTSIDE public supply well Zone of Contribution 4. Dwelling is connected to ❑ ON-SITE WELL PUBLIC WATER 5. Disposal works construction permit on file? Yes ❑ No 6. If yes, how many bedrooms were allowed by this permit: S_ bedrooms 7. Were building permits obtained for additional bedrooms? ❑ Yes ❑ No 8. Engineered septic system plan: a. On file at the Health Division? es ❑ No b. If proposed accessory unit is detached from principal dwelling, is that plan on file? ❑Yes ❑ No 9. Existing septic system capacity is bedrooms For the accessory unit to receive approval from the Health Department the =xisting ing action must occur: s stem accommodates ro osed additional bedroom s Y proposed O ❑ Upgrade existing system to accommodate additional bedroom(s) ❑ Must remove a bedroom from the main house ❑ Must connect detached structure to the existing septic system ❑ Must install septic system for the detached structure El Other No+e" 1--OP,� `lS OVQ?, � rat pw Signed _ Date 2 Commun ty.Pres&vation Act ACCESSORY AFFORDABLE APARTMENT LOAN'PROGRAM GUIDELINES PROGRAM REQUIREMENTS A Comprehensive Permit through the Zoning Board of Appeals is necessary to be eligible for the loan program. The Comprehensive Permit requires the apartment be leased to income eligible tenant(s) at an affordable rent limit with lease term of 12 months. The Town monitors the accessory apartment annually by verifying tenant income eligibility and apartment rent. The homeowner is required to provide this documentation to the Town. If the property owner does not comply with the Comprehensive Permit, in the first instance the Town will work with the property owner to resolve the non-compliance. If no resolution is found, the loan will be in default and shall be repaid according to the terms of the mortgage. THE LOAN A Contract with the Town is required, describing work to be performed. Only work listed in the Description is eligible to be paid from the Loan program Funds are a deferred payment 0% interest loan payable in full upon sale, transfer, refinance or loss of affordable unit. If the property is sold or transferred, the loan must be repaid in its entirety upon sale or transfer. The accessory apartment shall at all times comply with the Comprehensive Permit. If the unit is out of compliance the loan is in default. The loan is secured by a lien on the subject property which is recorded at the Barnstable County Registry of Deeds. * Please note- Any costs incurred prior to execution of the loan documents are not eligible for reimbursement. ELIGIBLE EXPENSES All work necessary to create the accessory apartment unit and/or to ensure that the apartment meets health, building and safety codes. Eligible rehabilitation work includes: Title V septic upgrade/repair, heating system installation/replacement, electrical/plumbing upgrades, insulation, window repair or replacement and egress improvements. If the rehabilitation costs exceed the amount of the loan, homeowners shall pay any remaining portion of rehabilitation/new construction costs. Costs that exceed the loan amount are the sole responsibility of the property owner. Funds are only disbursed to the contractor, not the homeowner, upon predetermined progress payment benchmarks, completion and inspection of the project. The homeowner shall submit the contractor's invoices to the Town for payment. * Please Note When the homeowner is qualified to perform the repairs, the Town will reimburse the homeowner for supplies only. The homeowner's labor is not eligible for reimbursement. Payment for supplies will be made upon submission of receipts for supplies and a project inspection PROCUREMENT GUIDELINES Homeowner is responsible for providing contractors with the procurement guidelines and contractor information and soliciting 3 quotes for all work to be completed. Contractors must be licensed in the State of Massachusetts. PROCESSING PAYMENT -Submission of executed W-9 from Contractor. -Funds are disbursed to the Contractor upon submission of payment request form and accompanying invoices with description of work and date of work. -Executed Loan Agreement, Mortgage and Promissory Note -Funds disbursed according to pre-determined progress payment benchmarks. r MARKETING AND RENTING The accessory apartment unit shall be marketed and rented on an open and fair basis to an income eligible individual. The Program requires the homeowner to list the availability of the unit with the Barnstable Housing Authority and Housing Assistance Corporation. The homeowner shall immediately notify the Accessory Apartment Coordinator when the accessory apartment becomes vacant. The homeowner shall submit tenant income verification documents to the Accessory Apartment Coordinator once a tenant is found. MONITORING Annually the homeowner shall submit documentation of the rent charged for the accessory apartment and the income of the tenant to the AAAP Coordinator. The homeowner and tenant shall provide any additional information, as deemed necessary by the AAAP Coordinator, to verify information. k¢r i3 Iy a ' k { FH� 5 g A`a l w } LS It). Lf e po No, 1 ., _ t, u - ��� p FAILED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI S DEPARTMENT OF-ENVIRONMENTAL P8_QTRECEIVED E.CT�Q r a a � -AAP 'A RCEL. DEC 0 $ 2004' aroT _�2- TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ),Cj '1Q4cb o 1* 0 Owner's Name: 5 Owner's Address: 0A ,t�het' 'rinlcJc, �'Q 1 j'11_ST fS1Q Date of Inspection:j Name'ofInspector: (please print) �A)cune— `;wL`QICA , ....Company Name: ciUi: Mailing Address: 1,etvre1'0-j e; Mo 0-9C._3.� Telephone Number; cX 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 Se* 15.340 of Title 5(310 CAM 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's 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 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 Page 2 of 11 OFFICIAL INSPECTION FORM*=NOT FOR VOLUNTARY ASSESSMENTS s ,- i SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART,A CERTIFICATION(continued) Property Address: ;_�r.��(� — ► its M, �— .— Owner: Date of Inspecti�� l n c 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"nof 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 a!fapproved 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: -nR 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)anereplaced. obstruction is removed distributi,oli box is leveled or replaced. ND explain: The system required pumping more than 4 times"a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS -SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner Rc,:r r >' Vct _ Date of Inspection: v:�j t In i.i 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: lid Cesspool or privy is within 50 feet of a surface water nc( 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. lQ 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. �C 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS (� SUBSURFACE SEWAGE DiSFOSAL S:YSTEM'INSPECTION FORM . s f CERTMCATIONN(continued) Property Address: 29 Tf •ic;h�. y4u-i Owner:. ('('y Date of Inspectioli:—117�, iL_4 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X 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''/i day flow Required pumping.more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 9� 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. X '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. 7� 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.analy#s ..This system'passes if the well water..analysis, performed at a DEP certified iaboratory;for enliform bacteria and volatile organic, Imp .co ' ds 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 S ppm,provided that no other:f0ure criteria are triggered.A copy of the analysis must*be tittaclied to this form.]. Y,eG (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 Systems: To be considered a large system the system must serve a facility with A design flow of 10,.000 gpd to 15i000 gpd. f ..t xr : You must indicate either"yes"or"no"to each'ofthe following: (The following criteria apply to large systems.in.addition to the criteria above) . yes. no 0 C 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 Gi— 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. ' Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ��Q Owner:Eu r c`\I Il'e_,ReSWhG Date of Inspection: 14. 1 1 Ire LA 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.? X _ 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 Sol]Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information. For-example, a-planat the Board of Health. _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J Page 6 of 1 l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ( SUBSURFACE SEWAGE: ISPOSAL SYSTEM INSPECTION FORM : .. PART C SYSTEM INFORMATION Property Address:] 'rhr:tohg:r t�c�fr I, Owner: Ain Date of Inspection:1J,► i O Li FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no):W Is laundry on a separate sewage system(yes or no):_fln[if yes separate inspection required] Laundry system inspected(yes or no): N eS Seasonal use:(yes or no):1DC) Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):-1)0 S'r'i�CIO @ i'l Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: . Design flow(based on 3.10 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— r 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: om.�_ tj L Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system .} _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight.tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if lknown)and source of information: e.Vt,titl Tn� alr/ji 1���� a+b"�l �1 t• r Were sewage odors detected when arriving at the site(yes or no): f Page 7 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS (C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: tj^j 1 h,n-.t 6or lie) ,�Icx� Owner: f�ar r, j .Date of Inspection; 110 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 'r 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: 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 0 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: M.eaS Comments(on pumping recommendations,inlet and outlet tee r baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): P PC 1`S 10 i 0 a- )f cckr; F mTy►r.�.,,..�.•_., s� cs,J Pc�tnt�n� ri�� _ GREASE TRAP:_(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.): Page 8 of 1 I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE--.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A<.thufiLh�f lil P,Q mr,`s�d4 _ Ownerr_Qf'l Date of Inspection:1 1 p 4 _ TIGHT or HOLDING 'TANK:TC4(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.): i` 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.): n { Glj PUMP CHAMBER:D_Q_(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.):. ' Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM (�. . PART C SYSTEM INFORMATION(continued) Property Address: 22f��4 r 11oi�ItL 4 M) 1 r Owner: Bae -d51�yw, Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,eacayation.not required) If SAS not located explain why: Type leaching pits,number:_ T leaching chambers,number: leaching galleries,number: leaching trenches,number, length: i-I �nifi'Itt`rxlc.^� ire' ilk' 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.): � `�:_�_t�j o;•j'r�Yl _ {.��� 1��al� O� t.�c:ate.t`A �lcle'.��t, S�t�n L Cad �V�t CESSPOOLS: r '4 (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: (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.): o I` Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2q f hu-t e zt" j4dkz�y Owner- Date Date of Inspection. .1 ,;, 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 ehters the building. �t&V 0 i 1� 1I% aC)� 3 P6 a ,�o' i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C PART C SYSTEM INFORMATION(continued) Property Address: ai 1.3 (��1 Owner: .� Date of Inspectio : 11 1 i 1 a SITE EXAM Slope Surface water, Check cellar Shallow wells Estimated depth to groundwater JO 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: r You must describe how you established the high ground water elevation: 11 • �i V_ ,A AY 2 2 2000 � / �� TOWN OF BARNSTABLE f , HEALTH DEPT. s F BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTI IJCATION Property Address: Date Of Inspection 3 6_Inspector's Name: Ow er's Name and Address: CERTIFICATION STATEMENT* j 1 Certify that I have personally Inspected the Sewage Disposal System at tr;is address and that the informa- tion reported below is true,accurate and complete as of the time of Inspec-ion.;The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maiu.tenance of On-Site Sewage Dis- posal Systems:T system t�' Passes ' Conditional►'. ses •' �> .', " :. '. Needs F he va ua ' y the Local Approving Authority Failu Inspector's Signature ''' Date:. TheS stem Inspector shall submit a copy of this Inspection Report to the AfProvin Authority with th Thirty (30)Days,of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Offie of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY: , A) SYSTE ASSES: I have not found any Information which i ndicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303, Any Failure Criteria not evaluated.are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined";explain why:not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is iimminent..The, will Pass Inspection.ifiExisting Septic Tank is Replaced with a conforming Septic Tanl-as Approved by the Board Of Health. 'Sewage Backup�or Breakout or,High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): -1 - kkvfj }ifSftsy aFS •f. ,(eY !, +.,k) {§ hfilN X�� �6e(+X{%L.x{"y�}tykM R''FN( 4fi�5� ( } i,.�:., t d'!fl t�'Y1 i 1 .tr,'i , ", Y"•,Ta`�'Sl f(�a,a '4! v ! f, SUBSURFACE SEWAGE DISPOSAL SYST,EM•INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced or obstr uctedpipe(s). keno The System required pumping more than four times a ye ar due to broken The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced _ObAiuction is removed' i 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM,.IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feetof 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 APPROPRIATE).DETERMINES THAT THE.SYSTEM IS FUNCTION- lING IN MANNER`THAT PROTECT THE-PUBLIC!HEALTH AND;SAFETY AND THE ENVIRONMENT:` The system'has aseptic tank and-soil absorption'system and is within loo Feet to.a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I,of a,public water supply well. ; The system has a septic tank and soil absorption system and is.within 50 Feet of,a private . water supply well. than 100 Feet but 50 The system has a septic.tank and soil absorption system and is less ee„ Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D)S YSTE M FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into-facility or system component due to an overloaded or clogged SAS or cesspool.l� Discharge or ponding of efluent to the surface of the ground(or surface waters due to an, overloaded or clogged SAS or cesspool: Static li4uid level in the distribution box'above:outlet.invert`due to an overloaded or clog- l• - .. e . 4t d.. .? s Vv3 Y! �...� tf .. ... 4 ged SAS or cesspoo - Y. i•less than 1/2 ., 'table volume s .. ,. . . 'nv rt or avar low� e Ligwd depth in cesspool is less than 6 be day now. Required pumping more than 4 tirlits iri the lasf year NOT due to clogged or,obstructed pipe(s): Number of times pumped 2- +4r, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) - Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. - Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 30 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because,one or more of the following'''' conditions exist ` The stem is within„400 Feet of a surface drinkin water su I _ system g PP.Y,�_ _._ • F 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 �^ The owner or operator of any such_system shall bring the system and facility into full complianoe'with'the groundwater treatment program'requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART B CHECKLIST Checkif the following have been:done:* -+ _Pumping information was requested of the owner,occupant,and Boaid of Health.; a} _done of the system components have been pumped for atleast two weeks and the system.has` "» been receiving normal flow rates during that period.'Large volumes of water have notbeen introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. !'F _jZ The system does not receive-non-sanitary or industrial waste flow., The site was inspected for signs of.breakout. system:components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened,andthe*inten4- tan of the septic k.was'in= " ` spotted for_condition of-baffles or tees cti,material of construon,:dimetasions,depth of liquid, depth of sludge,depth of scum. i �. The size and location of the Soil Absorptions'System on the site has been determined based on existing information or approximated by non-intrusivemethods. . -3- 1110 1 a r "s �alyycgf;M.id"�u,` `�q 1i t �,Cp F ' # 1M91n f t M1 ) PF' �.kP' i"ti' •1 1. ) )�I�a�• r' )M1 p� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST:(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM . .. - - PART.C SYSTEM INFORMATION FLOW CONDITIONS RESn ILL Design Flow:MO—gallons Number of Bedrooms: : Number of,Current.Residents:�_ Garbage Grinder: 1) Laundry Connected To System� Seasonal Use:�l- Water Meter,,Readings,ifavailable: LastDateof,O cy' -ZV-Y - cui Type of Establishment. " Deslgn;Flow "sallons/day Grease Trap Present' (yes or no) Industrial Waste Holding Tank,Present:. Non-SanitairWastesDischarged To-The Title V:System: WateuMeter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: Aji a . . GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection: If yes, olume pumped:.- ,1s lone Reason for.pumpuig. =c.. TYPE PSYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool „ Overflow•Cesspool Privy ; Shared System(If yes,attach previous.inspection records,if any) Other(explain): �- ,. ..... A1010ROX]DUTEAGE of all com nents, ate installed(if known)and source.of,informaddh:,..�.rs e odors det t when arriving at the site: e<; r .q_ °r`i�' i.nr€ '3 ' ✓ ,% t,+ 41-P= 43 {u•y,} 4jW' .TPI 5' (S'� 1? F r;t',� 1-� z.(✓ 'dri f SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM _ PART C GENERAL.INFORMATION (continued) SEPTIC TANK: Depth below grade: �1 Material of Construction:�oncrete metal FRP " Other (explain)s 3, — Dimisions: "X ' Sludge Depth: Scum Thickness:' Distance from top of sludge to bottom of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to oudet'invert,structural integrity,evidence of le ag etc. DGb �� n. t` GREASE TRAP:_,��' Depth Below Gra e: Material of Construction: concrete metal FRP Ut her (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: +' Comments: (recommendation for pumping,condition of inlet and oud6f tees or'baHles,depth of liquid ;3 level in relat of to.oud t invert;structural-iiitegrity:,evidence of leakage,etc) TIGHT OR HOLDING TANK Depth Below Grade: Material of Construction:__coticrete_metai_FRP Other(explain) Dimensions: Capacity; gallons Design Flow: gallons/day Alarm.Level: r Comments: (condition of inlet tee, condition of alarm and float swi(ches,etc.) —` .., DISTRIBUTION BOX: , Depth of liquid level above outlet invert: Comments: (note' el and distribution IS equal evi- dYce of solids c rryover,evidence of leakage into or out of box,etc 11 r PUW CE MBER:�.�'` _ Y .Ptunp is in working order.` Comments:'(note.condidon of.pump.chamber condition gf pumps and'appurtenances,etc.) 5_ . i u Tw. , < SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTIO14 SYSTEM(SAS):_ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain Type: i Leaching pits,number: , Leaching chambers,number: Leaching galleries,number 11.0ching4renches,number,'length: Leaching fields,number,,dimensions`: Overfi - ow 1 number:OeSSp00, , Co en (note condition o so signs of h draul' failure level of ponding,condition of vegetation, etc.;! _ y CESSPOOLS: Number and cdguration:> { ' `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(cesspool must be um as art of ( o inspection) I?� pumped P !� ) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of,vegetation,; etc.) "Ii n ft PRIVYalls j Mate 'n of construction: Dimensions: th of Solids:— Dep So ds: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, ' etc.) 10 ' - .. .r ..... .. _-..,.. .. ...«..,e_�.Y•�4�.4 :'".��iJt ..•t.]1.+........-...-.r.." ...�-Ji-+r°« ,q.�,�.• d .,+�!.,. 5: ' * t•�.�,t "ke t ., . a �...., -6 3 - SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or bencl arks. Locate all wells within 100 Feet. Ok LI lu O a �I i DEPTH TO GROUNDWATER: Depth to groundwater: Z/ Feet / Method of Determination or Appro 'matio A" Go.,-e" r� vz -7- ti TOWN OF BARNSTABLE LOCATION C&V SEWAGE# a C3�o I �o r(1,..r��.��,c VILLAGE �� �l ASSESSOR'S MAP &.LOT INSTALLER'S NAME&PHONE NO. � SEPTIC 'TANK CAPACITY t opo G a l l o ns - • LEACHING FACILITY: (type) �n f►'1 tt` ctt'-`a (size), NO.OF BEDROOMS_ BUILDER OR OWNER 2 ..n* ft o PERMftDATE: ; COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching-Facility (If any wells exist Feet on site or within 200 feet of leaching facility) cili If an wetlands exist Edge of Wetland and Leaching Fa ty( Y Feet within 300`feet of leaching facility) Furnished by I a - p4,��` 7 w ` . 4 M � tP I TOWN OF B STABLES ` LOC A O 2 j4�G ILoI'/ 0� �/ SEWAGE # 142 4gC VILLskGE /�ll/6J�� /LlJ�/5 ASSESSOR'S MAP & LOT//-/F'D0 INSTALLER'S NAME&PHONE NO. ��✓��� � �� 7T�-���� SEPTIC TANK CAPACITY /.,00O Ga LEACHING FACILITY: (type) -4 w C (size) /®X To �no2 NO.OF BEDROOMS BUILDER O OWNER PERMITDATE: /J-Z6-7 7 COMPLIANCE DATE: J Z- e 3-`t l Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom.of Leaching Facility S r Feet Private Water Supply Well and Leaching Facility (If any wells exist I/ on site or within 200 feet of leaching facility) f!/ Feet Edge of Wetland and Leaching Facility(If any wetlands exist 'within 300 feet of leaching facility) Feet Furnished by ! 4 61 } No. / L%' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for ligpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(�' )Upgrade( )Abandon( ) El Complete System 0 Individual Components Location Address or Lot No. 2 Owner's Name,Address and Tel./o. Assessor's Map/Parcel �^� ej" As K, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7)Jiff Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building 2 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /�19 gallons per day. Calculated daily flow X�91 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ��k �Xz�' its., Nature of Repairs or Alterations(Answer when applicable) 7-1 !e ZZ 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 Certifi- cate of Compliance has been issued y tVar of Health. Signed Date Application Approved b % Date Application Disapproved for the following'reasons Permit No. Date Issued '" E' 1� j P No. / � b/G/ {. 1 '-a�r � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓� Yes PUBLIC HEALTH:DIVISION'-TOWN OF BAft STABLE, MASSACHUSETTS 01ppli ratio"*for ;Di!5�iogai *pMent Con6truction Permit ,.. Application for a Permit to Construct( ..)Repair( /)Upgrade( )Abandon( ) El Complete System I�Individual Components Location Address or Lot No. Q �—/¢�� � �Q� wner's Name,Address and Tel. o. Assessor's Map/Parcel � ; Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grindef,(/'10 Other Type of Building wr G!/E'NGE' No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��� gallons per day. Calculated daily flow �- gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /ODDX�� Type of S.A.S. e*1S Description of Soil` �DX �X� Nature of Repairs or Alterations(Answer when applicable) 7`1��I—e 40' 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 Certifi- cate of Compliance has been issued y th' az f Health — " Signed Date Application Approved b Date Application Disapproved for the following reasons ot Permit No. " Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( so')Upgraded( ) Abandoned( )by at 2 /Ll�ilyrl�iGi � ias been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. r dated��"' ` R 7 Installer Designer The issuance of this permit shall not be construed as a guarantee that the sys ill fu�,c s designed. y Date Z ' -7 Inspector �� - h4a�e'l ,or ------------------- ''"6 — --------- No. ?/�°' ��� �4"vl Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 33i5pont *P!6tem on5truction Permit Permission is hereby granted to onstruc ( )Reppair( Upgrade(f )Abandon( ) System located at TAa'rG,el", /�;,/tva Vr0� /�tri"57Dlrs .�'1f;/ s and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this Re Date: f�'"" L '" Approved by� �/G • 1019/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, �joe,�'�` ,�Q/�I`O�Oj,�hereby certify that the application for disposal works construction p g Y cti permit signed b me dated concerning the 1 - p property located at �� ��ll� �i^ ���'� 1O7- meets all of the following criteria: ✓ There are no wetlands located within 100 feet of the proposed leaching facility /There are no private wells within 15o feet of the proposed septic system There is no increase in flow and/or change in use proposed 1� ere are no variances requested or needed. • If the proposed leaching facility w111 be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.cent � AY 10 �t u i i J I i ,4 �ro 6 r� TOWN OF B STABLE C/ 1. :,� .. ... 'LOCATION Zq � /tf�/�wtr/ SEWAGE # VILLAGE /rlll/'61`� �/J��S ASSESSOR'S MAP& LOT/- 8' y> INSTALLER'S NAME&PHONE NO. 406Pr*Z4 CD,O'�5T 77/-939� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) w�l l�l�-� ��) (size) AO X NO.OF BEDROOMS 3 M � S�nI> � BUILDER o wNER j PERMTTDAM P-06—?7 COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist % :'' ✓� Feet"::<;`: on site or within 200 feet of leaching facility) _. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet:. Vui ished by TOWN OF BARNSTABLE LOCATION '�� Th�tt/��-c ���� � RP SEWAGE# a 0Q�o 14 VII,LAGE.ICA V AtO Inc, rn►'li_� ASSESSOR'S MAP &.LOT INSTALLER'S NAME&PHONE NO. tope,.u�iinl SEPTIC 'TANK CAPACITY 1000 2 0 L 1 o ctS LEACHINGFACium (type) S—In krct e C-65 (size).3�(0`1- 0X16"1) NO.OF BEDROOMS, 3 BUILDER OR OWNER RaP(`T PERMUDATE: } - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching-Facility (If any wells exist ' on site or within 200 feet'of leaching facility) Feet -edge of Wetland and Leaching Facility(If any wetlands exist within 300"feet of leaching facility) Feet Funiished by TOWN OF BARNSTABLE LOCATION a G Q1C.hP-C 116-1 LZCL V RD SEWAGE # VILLAGE ( alu',to nS m ili_q ASSESSOR'S MAP & LOT 1 i�S ob4r INSTALLER'S NAME&PHONE NO. �a p e_0 J e- g n i Vr p c%SeS So SEPTIC TANK CAPACITY 1002 gallons , oAg LEACHING FACILITY: (type) f1'1 r ratoc_% (size) 36o'l. 'f: WO is 1 "D ENO.OF BEDROOMS 3 .BUILDER OR OWNER Baru 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 leaching facility) Feet Furnished by Ai= IW� (�1- i i" ��,��� 6a 4 . ® + o .�� � ``� a t _`�. � � r pk,3 ' t O � TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT ,' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by No. (Jds 0l b _ E Fee l GI V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -Yes Yess PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for ;Mi5pont 6potem Con.5truction Permit Application for a Permit to Construct( V)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ;�C' Owner's Name,Address and Tel.No. 5,gfm y Assessor'sMap/ParceI 11 +9-I F� �) 29roa4fzlrKf/��aJweo.-1 e/2� 5�p� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C �.c. t7©x ��3 �S�"�5T G✓a�E ss- CeL,rY(.i(le Md� ort3z S�gyL�yo2� r�� ��el3ccxr vi'lI�C�23:/G J-6T Y6<i_23 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons .3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3•o gallons per day. Calculated daily flow 3-3 y- y -gallons. Plan Date L 2 - R- oy Number of sheets I Revision Date Title 1-In iLt✓� w Size of Septic Tank 1,000 !!�c f Type of S.A.S. —lid ZOE rX,1tort STbrt Description of Soil (oa n1ti Nature re of Repairs or Alterations(Answer when applicable) c f�,,t di,G, JM )�i Ji' -- Date last inspected: ( ' Z®—'yooq 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed Date /_ -7-2-© Application Approved by Date Application Disapproved for a following reasons Permit No.2a0 510 I Date Issued l— U �U�S - O(� M No. %: v t — Fees THE COMMONWEALTH OF MASSACHUSETTS r . Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Wgpoof *pgtem Congtruction Permit' Application for a Permit to Construct(v)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a C' �Li 197C�I P/�' Noll✓R C1 Owner's Name,Address and Tel.No. Assessor'sMap/Parcel /L4 6 f f� � '' ,n Q�s anlrc4ivt k 140) w✓�-1 az. � 4/tL r,o; Installer's Name,Address,and Tel.No. '�C Designer's Name,Address and Tel.No. R.-c�n,d Gips/ CnpewtGle �,�cr�i�3PS t_C. C �v,7 -3r4krC �r,f,Anr;-� P o. t7o u 9co 3 Vol, 6 S- /ls1 C./o u G St" Ce rYe -�(le ozG3i srgtize plti ��< t3oi� YYJ�16Z3VL f�g9YG�,Z3 Type of Building: Dwelling No.of Bedrooms 3 Lot Size Z/, sq.ft. Garbage Grinder( ) Other Type of Building Ic No.of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 gallons per day. Calculated daily flow 33 y- 11 gallons. Plan Date 12 - IQ - o`( Number of sheets l Revision Date Title -4, 114 v4 ti", w Size of Septic Tank I.00D !!�A J Type of S.A.S. 6-_4 1/4 46r1169f&tf 57-0'LQ Description of Soil 50+J (0 VAC i2�r R Coam yS d IO V2 3o Nature of Repairs or Alterations(Answer when applicable) eA)4c t 1�.,./ L,6,) r/)2 fo4 S (,Jc 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed Date I- 7—Zo o> Application Approved by Date/ 7"aS Application Disapproved for a following reasons Permit No. �2 44)6 �_-n l to Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired ( )Upgraded( ) `Abandoned( )by at aS T a4-Tt1 gn i 1�41wA4 M V4Js t'o,n 1 M i115 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 Od.S-G/ dated-- 7-U S_ Installer GA w*,&o Vh6ell;)el Designer «tl n The issuance I pf this permit shall not be construed as a guarantee that the sys� wilfifurn�tion as desig ed. Date �:D 5 Inspector I No. C)�� , Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogaf *pgtem congtruction permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 7)6 I�t a i �.�t J�o I w r1��,�.� i�i t1> 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:Constructio must be completed within three years of the date of this�erm�t. Date:_ 7 U Approved by j A t, P, d T I LOCATION � ,�jSEWAG PERMIT0. VILLAGE l INSTA LLE-R' NAME i ADDRESS - BUILDER OR OWN ER � a 0o -L, ,v" DATE PERMIT ISSUED - t 7 fi DATE COMPLIANCE ISSUED o u ���' ��n- r� � � �. ,�., " �,p � �D � f .� .. y� � � � ... i �y . �I u Fawn of Barnstable °FISE T°w Regulatory Services h G� Thomas F.Geiler,Director Public Health Division E0 �R Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Forte Date: v Designer: _JAA' t Installer: Address: (o 5 L P5,% (9(2 av L 5%. Address: u u (� k x 7 63 �if� On. CS �+ C �O1:1 <j___-was issued a permit to install a d te) (installer) septic system at T14 A-T6 6-K 11 O Lw A-q RD based on a design drawn by �p (address) �l�M P V LI K P. E. dated 1 ZJ ( 104 (designer) I certify that-the septic system referenced above was.installed substantiallyaccording to the design, which may include minor approved changes such as lateral reocation 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 component of the septic system)but in accordance with State&Local Regulations. Plan'revision or certified as-built by designer to follow. tke OF Mgss9c A DAMES A. yGu, o PAVt_IK aller's(hg S' tore) CIVIL -� CD ► O.36468 10 9p`F SFt'STERF AL EN (Desigaer's Signature) (Affix Designer's Stamp Here) P ASE RETURN TO BARNSTABLE PUBLIC HEALTH:DIVISION. CERTIFICATE OF COMPLIANCE WII,L NOT BE ISSUED OTH THIS FORM.AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE P LIC HEALTH DIVISION THANK YOU. Q:Health/Septic/Desiper Certification Form No...................... Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD H EALT� OF..........7t4 C .................. Appliratiou for Dhipv,13al Workti Tomitrurtion Prrmit Application is hereby made for a Permit to Construct (wel"'or Repair an Individual Sewage Disposal- System at: .. ......................... . ................. Location-Address or Lot No. ------------------------------------------------------------------------------------------------ ............... r—.`.- .K:...... .......................... _. Owner Address .......... ............ ................................. .................................................................................................. Installer Address Type of Building Size7 .....Sq. feet ---------- U Garbage Grinder Dwelling—No. of Bedrooms.__.........................................Expansion Attic '-_l PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 Other fixtures --------------------------------- ................................................ . ...................... .< '~'M WDesign Flow......./Zo............................gallons per pep_"mper day. Total daily flow._._........ .........gallons. 1:4 Septic Tank—Liquid capacity/420.0.gallons Length---&........ Width_____ ......... Diameter................ D' epth... Disposal Trench—No. .................... Width.................... Total Length...................... Total leaching area.....................sq. f t. Seepage Pit No------/........... Diameter,/OA-.5. below inlet....�� Total leaching area.Z­&.�R.....sq. tf .... Depth b ..!....... Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by..____.. ....................... Date.... . /.. ............. Test Pit No. I_-.!< —. --" Minutes per inch Depth of Test Pitoo0V. _Y_c..... Depth to groundpwa Test Pit No. 2_,-.<.3m._minutes per inch Depth of Test Pit/_,V.,Y~.... Depth to ground water.Adq --------- Z.............a...... -Y__.W --.----............-..............Description of Soil........e--------0----- ......U .... .....Ov. .......6-0, .V........fl�.../..... . ------------------- Z-------- ------------ ---- ---------- .......... U Nature of Repairs or Alterations—Answer when applicable.___________________________________ ---------- ............. . ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TA-ITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i tied by the and of health Si n( ...t4.4 �,LU 9 ........ Date .......... ------ Application Approved By.......... .. .-6.A- ............. ..../ ­7f A411 Date I Application Disapproved for the following reasons:--.............................................................................................................. .........................................................................................................I......................­------­----­------------........................................ el:;Date PermitNo......................................................... Issued_ ...7............. Date j 1 y S N090 6— THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT + .__.....OF........... ......................... Appliration for Uiipoii al Works Tonitratr#ion Vantit Application is hereby made'fora Permit to Construct (u.�or Repair ( ) an Individual Sewage Disposal System at: / 4 Location-Address / or Lot No. . , Owner Address Installer Address �ry _ QType of Building Size Lot.Z4 e.`.. _._..Sq. feet V Dwelling—No. of Bedrooms____._ ...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria Pa Other fixtures . �• _ W Design Flow.......IZ.0............................gallons per persomper day. Total daily flow------______.-_--: ..........gallons. WSeptic Tank—Liquid capacity/c J..gallons .Length._. ?........ Width-----2--------- Diameter________________ Depth... . ...... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------- Diameter_/0,_5_"__ Depth below inlet.._r Total leaching _ .sq. ft. Z Other Distribution box ( Dosing tank Percolation Test Results Performed by.......... ._.....:-- ._ Date.... Ker -e­'J.oj_V a Test Pit No. I__-�----•:.minutes per inch Depth of Test Pit/9, "f:____.. Depth to ground wa .�_.._. Test Pit No. 2.t<..3-_.._minutes per inch Depth of Test Pit/..�e-.'y--_...... Depth to ground water. a ----------------------------------------------------------------------------•-------------------•-------•------------------------------------------ r O Description of Soil................. --------------------------- ------.... .--- ----- x' i_'. � ' d;= e r --------U. Nature of Repairs or Alterations—Answer when applicable--------::.........................: ....----._...._...._.!�. ...................._„_--__. •---•-----••-------------------------------------------------•---------------------•---•---•-----------------------------------••---------------------------------------.............................. Agreement: The undersigned agrees to install the aforedescribed Individual`Sewage Disposal System in accordance with the provisions of i T y g g p, y 5 of the State Sanitary Code—The undersigned further gees not to place the system in operation until a Certificate of Compliance has been�sued he rd of health. Sign ? :_ .:... .:.. �r�J.: ._.. Dat� Application Approved,-B v �j.1,� L._ l3'.:7.............. ` Date Application Disapproved for.the following reasons---------------------------------------------------------------•--------•---------------.... --•---------•.----- .................................................... .................................................. ` Date PermitNo---------------------------------------------------------- Issued.---•--------------------•-•----...................... } Date } THE COMMONWEALTH OF MASSACHUSETTS ram•' BOARD OF HEALTH - ............... ...1......OF........... . .l ........... CIrrtifgratr of TontpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�or Repaired ( ) by---- .......•. ::.-----•---- ------------------•------ ---------•.......----- -------------------------------------------------.--.----------------- Installer f� at...'` .� � r C /=13-11---------------------------------------------------------------------- has been installed in accordance with the provi ' ns of T i. j of The State Sanitary Code as described in the ... application for Disposal Works Construction Permit IN . __.. .... ................... dated..... ..._.._..._._......_. THE ISSUANC'`E OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM. WILL FUNCTION SATISFACTORY. DATE................•---•---•---•----------•----•-------•------.....------•---•----- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH 7)q No......................... FEE........................ r Diapopu1 Vorb 0-Kagno#r ion rrntit Permission is hereby granted... ClA Permission to Construct (1�or Repair'( ) an Individual Sewage Disposal System at No. . ..............?r11A Cl! 1a... •. t G Street as shown on the application for Disposal Works Constructio It No..................... Dated.........------------.---..---.--------- Board of AValth DATE------ -------•----------------------------------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Town of Barnstable Health Inspector Office Hours Regulatory Services 8:00-9:30 ; Thomas F.Geiler,Director 3:30—4:30 STAB Only 9� A r Public Health Division Boy Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: !� Address: Z9 V 0" Map 45 Parcel Name: [ 7 tx 17C Phone: 654 ZZI- �712-- 2. How many bedrooms exist on your property now`? Are you planning to add any bedrooms? PC) 2a. Please include a copy of your floor plans for the entire property. 3. Is the dwelling connected to public sewer? YES or (Ro ) If the dwelling is connected to public sewer, skip questions 4-9 below. 4. Location of dwelling is �DEOUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WA TE 9 6. Is a disposal works construction permit on file? YES or NO 6a.If yes, how many bedrooms were approved according to this permit? Bedrooms. = 7. Were any building permits obtained for construction of additional bedrooms? YESI or a= 8. Is there an engineered septic system plan on file at the Health Division. YES oZ NO" 9. Has the septic system been inspected by a DEP certified inspector within the lastv,vo year32 YES or NO �v © r ko rn FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public Health Division has n. objection to t� bedrooms at this property. Signe Date: Inspector(Print): �, '(`P1 �— QU 6o��+� ( lLo awn Q;/health,wpfiles/amnestyapp �T LS�(i L-es b&j� C ULW 0'W r- (fir&fib N n;�xl�. fifr i KokR-T UE ATE p )oo 4 IC ri c a I a k o r -CP f i , � R f � } L _. 'Ulso- F Fe a im (,Ue z f d j[� f rn ILLS 1 1 _ Los ' } i _- -..�,-•-�.-'-•--.<--......ram_.-.v- ,.-.'...-.-,...-....a.x,:y�-�a��.�5,r.,.--.>-.��..,.._,..t.�. .,_. ... -__.. G/7 e I i a f 5 F 1 A t - o a r 3 2 }� 1 I BENCH MARK: TOP OF FND. a (n)S pccT/vr (SAS) SHALL BE ELE.= D. t O r 44.25' LONG11.0' WIDE _ MANHOLE COVERS TO EXTEND TO pOk r 10DEEP ��- WT HJN €rti OF FINISH GRADE BAFFLE REQ'D EL=:5 5.33 (N Ewe � r 1 o�ti 2' PEASTONE TOPPING - SS.S D.B. __ _ -- _ - -- vEw T RE6'�) CAP ENDS GENERAL NOTES: (,P I. TA►,4 K Zp — "- S -- -_ _ _- " - -�-stoNE ADOUil AROWUNOED — SYSTEM PIPE SLEVATIONS OHALL WN eE EITHER C.I.ED ON OR DATUM. EL—5 cl..o0 SCHEDULE 40 P.V.C. `2, — THE BOARD OF HEALTH SHALL BE NOTIFIED 1.5 31.25' .5 PRIOR TO BACKFILLING OF SEPTIC SYSTEM. 20' MIN. — SEPTIC SYSTEM STRUCTURAL. COMPONENTS USE FIVE (5) INFILTRATORS SHALL BE CAPABLE OF WITHS1KNDING A SOIL TEST Loc �� �Z���/O4 PROPOSED SEPTIC SYSTEM WITH *'� OF STONE A SIDES H-10 LOADING. UNLESS SPECIFIED OTHERWISE ;1.5- OF STONE O ENDS — SEPTIC SYSTEM UNDER DRIVEWAYS SHALL pERC RATE—< 2 MIN/INCH NO SCALE NO'STONE AT BOTTOM 5-5 COMPLY WITH A H-20 LOADING. 120 ' + — THE DESIGN AND COMPONENTS OF THE SEPTIC oEpTH ELE� 5 S•50 , SYSTEM SHALL BE IN COMPLIANCE WITH THE 0 311 STATE OF MASSACHUSETTS SANITARY CODE A.LOAMY SAND 10YR LOAMY sANn � \ �L= �'$•SO TITLE V. AND SHALL BE IN COMPLIANCE WITH 30" FICI � �erToN T��'r 140LG THE LOCAL BOARD OF HEALTH RULES AND REGULATIONS. ME" SANG 1oYR �I3 G Ir l sTacc, NO �J A 7 /0 — THE CONTRACTOR SHALL BE RESPONSIBLE FOR O r -nE� �x�s ; LOCATION OF ALL UNDERGROUND UTILITIES AND 5,A•5, A n1 0 R�PLhLC a SHALL NOTIFY DIG — SAFE PRIOR TO /O' 48•So ►r w�TT T-14- NEB° CONSTRUCTION. ` S 1 NO GARBAGE GRINDER Su«. CvAcvA77ot,1 BY : f. PAVLik cAN, inT ©133Eit VE-0 CV tq•°�° 0&j T-1415 p +I� ���+ DESIGN CRITERIA: n WAT - DESIGN FLOW 3 BEDROOMS AT 110 G.P.B. / DAY 330 G.P.D. LEGEND: � v- s, E)asnNG CONTOUR — — — — — (oo +I q E S'�• Z•A rr REQUIRED SEPTIC TANK: • `� �/, USA._ xr rtglG _ 11000 >AL. rAr,1K- WTEST ATER HOLE SERVICE —�— O ��� SEPTIC TANK PROVIDED c GAS SERVICE G—G— dQ 0 DESIGN PERC RATE <2 MIN/INCH BENCH MARK QBM ` �� �t� SIZE- OF REQ'D. (SAS) AREA = 330/0.74 446 S.F. EXfSr- Spur EcE�, 59.50 55 ° I(o �1�l '`';f SIDEWALL 1)= 75.12 S.F G� � ILI' � BOTTOM �2)%83)(34.25)+(2)(O.83)(l 11 4.25) — 376.75 S.F. NOTE: c�'' �x� 6M SIZE OF LEACHING FACILITY PROVIDED: PRIOR TO 94STALLING THE NEW (SAS) THE <,p0• 376.75 S.F. + 75.12 S.F. = 451.87 S.F. CONTRACTAND BACK�FILL WITH c'LF SHALL M MEDIUM SAND �C•O��•' � t7� �5O M(�� ( LI.�j / LOT S �' = 334.4 GP IF LEAcA-PITS ARE ENCOUNTERED IN THE (SAS) AREA THEY SHALL BE REMOVED �1 2ti Tt-�T F�c� a s= O. So JAG 2e EFFECTIVE DEPTH: 100 z L EFFECTIVE LENGTH: 34.25' EFFECTIVE WIDTH: 11.0' ~p _ OUTBACK ENGINEERING .t- ___. I,05_e45r GROVE STREET 8 �ayati Ass90 MIDOLEBORO. MA 02346 JAMES A. ya MS) 946—M l S 8 o PAVLIK �, PROJECT: SEPTIC SYSTEM REPAIR S: U I ± No 36488 Z 1 T M A'1-G f4ELZ 14 0 LW/� 2D s6 '_ - --� --� — $� M e/ o�'o` 9COS E c�0 Q ' ar.�a AS SHOWN ._ .. ,,Z ..' :< Fs N �� ome Il-I �- ay MAP Icy$/ LOT g .n. ` AB TH A T C H EI� L W A y OWNER: 3Al2K Y Z PATRI GiA 13E1CCS A 1<A Z - 21 --09 Zq 7-I44TcNec ftL,WAY o MSc.t �-0-.�____�._...__..,.. _ ' _ ._._.-- ----- --�- .._ _ _..;.____ _________ .__ -- -- -- -� ---- ---___ -- -- - - --_ __.-- . ------__r_..�-.._�._ -+- -Et_E�1-�'r`t'dF3 ��{y-'y- f� -vet'•`fi�#-'_--E-tEAtt3'--��t�t+�F---�+.?•�r-~#--_ xG /eCL f -f- 33.CO 3.z5 �n 3�:75s---_ ._ 8- __ -t \32- G3 ------- s _ .-Zu�c�:;:� ��'�o`'i� -- _._• - 1._-_ .___�.- - _. _.-- h ------- ,. "`__—__._..._,{._._.-._.�._.._.�.�-._�- ? - •, - - -t- z 3 13 i ,24 1 r 7 fixis�/r19 9rouncl pr-ofl O - S G T 0 / - --- - —o —o—o—o-- ProposGa/ c�r'our7cl / �/ (/ E ST SG �7L � / _ /O / SCH&O. 40 PV C. O/2 -.. FL OW 1 EgU,o9L TD '$EPTJG %z" was.�-ieo/ stone ; � m;nirrrurn /,+ Per foot --- t — /^J -T -T \ C' s Ye— Ito k ° O/ST BOX , ell Sump 54 /0oo GAz-. .6 P7- TANK Cf 3/♦ - //r 1 e � • /i washed �. , - OIV e- � TA / � S - a� 33- � � w 7-� 7- HoL E- L oG BEORooM H0USE O�9TE : L�-.1 TE5T � LL__ C r7o c//s,poser > / - PHUL /''IU2�2 RY Q��nf M//V //VCH Gt//T�lESS o Go�rpr 1 �,\ FL OW .SATE �� Gf)LS.�OAY o f f/ea /ff k ke' 3(d�,o' �o��` , 'fi ?� x OATuM M•S L. t �o t' Lo o-�' � � b .e- t S E P T/ G TANK �-�-• _ / S �- Y U5C- ;:»: '_ GAG . Tr9A./KHOLE �•• 90 LEAG H P/T /Oct rrr F /oa IT? E S/OEN/AGL �_/ � '�S.F � �• � _ �`� � GAGS. OA7� )� / BOTTOM c4- v& -"5.F L.Of % \ /'byL TOTAL - GAGS �A�pY� o a J �'_'_ ice, S�k USE: / LEACH F�sT Goa r5p co L 1-44 CE'�eT/FY THAT THE• BU/LO/NG P/E'OPOS•EO Oti/ THE G�OU/VO R _ FAN !il//L r{ S H O lit/N O JV TH `F w+ ��• di ,, -', .� CO/VFO�M TO THE BU/Lp//VG } .f sir -7-HATC�-I h' • y • E x a: - K -40' 'he vF� _ -'• � x HIV tat -, �d > lowl J?2. �' � Mtwc- Qi F a �,&fi r ' N v .�,. »t' :��, a ! A 1s:is S G A G E . �S s �© •n A` C) T9 7 !7 — �?�` � Ccyr r��,. �," e s J J -� - -o E- C O A-/ Z- .-q/'`!/V/A/G G 7-& S /NG. T O E /V nJ/S S S. SGIqL & r9 P F!e O v-_ O --- - = -- - - - - BoAAEGO 0 HEf�LTH / , o - o o -- orOPoS@d 60 /7-�"OUr5 � f� / _'�' r d G r• /✓7,49 .5.`7