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HomeMy WebLinkAbout2175 SERVICE ROAD - Health 2175 Service Road W. Barnstable A = 214 071 r 0 7 Ca I Lf Commonwealth of Massachusetts Co Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name sequin required is West Barnstable MA 02668 May 18, 2021 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information SI filling out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Co � Company Address Forestdale _ MA 02644 Citylrown State Zip Code 508-888-6055 S112843 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 16.000); 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. 0 Passes 2. Conditionally Passes 3. Needs Further Evaluation by the Local Approving Authority 4. Fails May 20, 2021 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is Y West Barnstable MA 02668 May 18 2021 required for every , 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: 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, NDyfor the following statements. If"not determined," please explain. // i The septic tank is metal and over 20 years old* or the s Iptic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration tank failure is imminent. System will pass inspection if the existing tank is replaced with a comp ing 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 0 years old is available. ❑ Y ❑ N ❑ ND (Explain bow): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Commonwealth of Massachusetts r Title 5 Official Inspection Formepi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Adc ress Richard Leonard Owner Owners Name information is West Barnstable MA 02668 May 18, 2021 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break ou or high static water level in the distribution box due to Broken or obstructed pipe(s) or due to broken, settled or uneven distribution box. System will pass inspection if(with approval of Boar of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is levele 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 f rther evaluation by the Board of Health in order to determine if the system is failing to protect ublic health, safety or the environment. a. System will pass unles Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sys m is not functioning in a manner which will protect public health, safety and the environ ent: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is west Barnstable MA 02668 May 18, 2021 required for every y 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 o ealth (and Public Water Supplier, if any) determines that the system is fun cti ing in a manner that protects the public health, safety and environment: ❑ The system has a septic tank d soil absorption system (SAS) and the SAS is within 100 feet of a surface water suppl or tributary to a surface water supply. ❑ The system has a septic to and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic ank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a se is tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private wat r supply well**. Method used to deter ne distance: **This system passes 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 El ® 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is West Barnstable MA 02668 May 18, 2021 required for every y 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 '/z 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 privyis within 50 feet of a private water supply well. P PP Y ❑ ® 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 f ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is y ithin 200 feet of a tributary to a surface drinking water supply ❑ the system i located in a nitrogen sensitive area(Interim Wellhead Protection Area—IW A) or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is y West Barnstable MA 02668 May 18 2021 requi-ed for every , 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) ® ❑ 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 a 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)] 5nsp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is Y West Barnstable MA 02668 May 18 2021 required for every , City/Town/Town State page. tY 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): 356 GPD 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: Septic Tank Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Private Well Detail: Well located >150 from leach field. Sump pum ? ❑ Yes ® No P Last date of occupancy: Current Date ` t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is y West Barnstable MA 02668 May 18 2021 required for every , page. City/Town 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 itle 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Ready Rooter records: Pumped May 3, 2021 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 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owne Owner's Name information is y West Barnstable MA 02668 May 18 2021 required for every , 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: System installed 07/12/2002. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.712612018 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 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is West Barnstable MA 02668 May 18 2021 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 12.5' x 5.5'x 4.5' 1500 gallon Poly , Sludge depth: <111 Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness <1" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Inlet risers brings inlet 24" poly cover within 4"of grade. Outlet has 20" metal ring and cover 4" below grade. Tank openings are not round. Recommend maintenance pumping every two years with full time use. I i t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is y West Barnstable MA 02668 May 18 2021 required for every , page. CitylTown 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 t/botfttom t tee or baffle Distance from bottom of scof 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.): J ' 8. Tight or Holding Tank(tank must be pumpe 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 I c Commonwealth of Massachusetts 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2175 Service Road _ Property Address Richard Leonard Owner Owner's Name information is y west Barnstable MA 02668 May 18 2021 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 s tches, 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.): One inlet, two outlets. Speed levelers in place. H-20 DB-3 is 4' below grade. No sign of high water staining over outlet inverts. Marked with 2" PVC pipe due to location. Property drops over 30'from tank to leach field. Riser and 18"concrete cover bring access within 6"of grade. 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 i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is required for every West Barnstable MA 02668 May 18, 2021 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 cham/r, ndition 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: 2-500 gal ea. w/ ® leaching chambers number. 4' of stone ❑ leaching galleries number: ❑ leaching trenches number, length: El 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 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard _ Owner Owner's Name information is West Barnstable MA 02668 May 18, 2021 ' required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers inspected with camera. Liquid level 1.5' below invert at time of inspection. Light high water staining 1' below invert. Clean stone visible in side wall. No sign of past hydraulic failure. Leach field 4 5' below grade No vent found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet inve/of Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of solic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner owners Name information is required for every west Barnstable MA 02668 May 18, 2021 page. City/Town 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 o 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. " 2175 Service Road Property Address Richard Leonard Owner owner's Name information is required for every West Barnstable MA 02668 May 18, 2021 page. Cityrrown 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 t S'C' t5insp.doc•rev.726r1018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts +� Title 5 Official Inspection Form F e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 2175 Service Road Property Address Richard Leonard Owner Owner's Name information for every y ation is required west Barnstable MA 02668 May 18, 2021 page. Cityrrown 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: >5 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. 08/29/1999 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: maps.massg is.state.ma.us/oliver.ph You must describe how you established the high ground water elevation: Engineered plans from 1999 determined adjusted high ground waterat elv= 35. Base of chambers at elv=61 per engineered plans. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner owner's Name information is West Barnstable MA 02668 May 18 2021 required for every -- __ Y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 04P)e • 2175 Service Road t•`� - --- I° Property Address Richard Leonard Owner Owner's Name1 information is r.• required for every West Barnsta__ble;/ _ MA 02668 August 3, 2015 page. City/Town State Zip Code Date of Inspection j 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. General Information on the computer, use only the tab 1. Inspector: [/✓ / j key to Trove your I cursor-do not Patrick T. Sullivan ! use the return Name of Inspector key. Ready Rooter Excavating i Company Name — -- P.O. Box 89 Company Address i Forestdale _ MA 02644 City/Town State Zip Code I 508-888-6055 S112843 Telephone Number License Number j j B. Certification I certify that I have personally inspected the sewage disposal system at this address and thatjthe information reported below is true, accurate and complete as of the time of the inspection. Th'e inspection was performed based on my training and experience in the proper function and maintenance lof on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: I ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i �Signaue--`��--�� August 4, 2015 InspeDate i 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. ! xtt* , 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. �0 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy em•Page 1 of 17 I Commonwealth of Massachusetts W Title 5 Official h Inspection Form Subsurface Sewa ge e Di -g Disposal System Form Not for Voluntary Assessments 2175 Service Road Property Address - — -- Richard Leonard Owner Owner's Name information is West Barnstable MA _ 02668 August 3, 2015 _ required for every — g page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D I A) 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y,N, ND)for the following statements.!if"not determined," please explain. The septic tank is metal and over 20 years old* oir the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfil ration or tank failure is imminent. System will pass inspection if the existing tank is replaced withcomplying 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): t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is West Barnstable MA 02668 August 3, 2015 required for every — � page. City/Town State Zip Code Date of Inspection B. Ce rtification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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 be;low): r i ❑ The system required pumping more than 4 times a year due to broken or obstructed 1 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 be'low): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further' evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system/is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 2175 Service_Road__ Property Address Richard Leonard _ Owner Owner's Name information is West Barnstable MA 02668 August 3 2015 .required for every g , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the publiclhealth, 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 �iurface 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 andhe 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 a 4 lysis, performed at a DEP certified laboratory„for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: / / D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ; �,• 2175 Service Road Property Address -- Richard Leonard _ Owner Owner's Name information is West Barnstable MA 02668 August 3, 2015 required for every _ _ g page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the:presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner,should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or no" to each of the following, in addition to the questions in Section D. i Yes No i ❑ ❑ the system is within 490 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is Igbated 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 2175 Service_Road Property Address - - ------ - — — — - --- — Richard Leonard Owner Owner's Name required for is every West Barnstable required for eve MA 02668 August 3, 2015 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the-following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 -- Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 356 GPD 15ins•3/.3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •' 2175 Service Road Property Address --- — — — Richard Leonard Owner Owner's Name — information is required for every West Barnstable _ MA 02668 August 3, 2015 _ page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Private well Detail Well located >150 from edge of SAS. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): / Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., Grease ?trap present? � ❑ Yes ❑ No Industrial waste holding tank present El Yes ❑ No Non-sanitary waste discharged tothe Title 5 system? ❑ Yes ❑ No Water meter readings, if avail b/: t5ins•3I13 Title 5 Official Inspection Form:Subsurface Disposal Sewage Dis g p System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road__ Property Address ------ --- Richard Leonard Owner Owner's Name information is required for every West Barnstable MA 02668 _ August 3, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owners records: Pumped summer 2013 _ Was system pumped as part of the inspection? ❑ Yes [R No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ 8 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •' 2175 Service Road Property Address --- Richard Leonard Owner Owner's Name inforrration is required for every West Barnstable MA 02668 August 3, 2015 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 07/12/2002. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 2 - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 16" feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 12' x 5' x 4.5' 1500 gal poly tank Sludge depth: 3 -- t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address ---- zl Richard Leonard Owner Owner's Name information is West Barnstable MA 02668 August 3, 2015 required for every g page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 — Scum thickness 2" at inlet, <1"at outlet Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" ---- How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Inlet has 24" riser with 24" Polyloc cover 2" below grade. Secured w/ 3-5/16" hex screws. Outlet riser brings 20" metal cover 4" below grade. Openings to tank are not round, tank has settled. Not affecting system operation at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: / ❑ concrete ❑ metal ;'•❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: / — 1 Scum thickness — --- Distance from top of scum to p of outlet tee or baffle — Distance from bottom of slum to bottom of outlet tee or baffle --- Date of last pumping: Date tins•3,13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M _-,•'� 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is west Barnstable MA 02668 August 3, 2015 required for every _ _ 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - Material of construction: ❑ concrete ❑ metal ❑fib'lass ❑ polyethylene ❑ other(explain): Dimensions: f Capacity: ' f gallons Design Flow: gallons per day Alarm present: % ❑ Yes ❑ No Alarm level: / Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3.13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard Owner Owner's Name information is West Barnstable _MA 02668 August 3, 2015 required for every _ — 9 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, two outlets w/speed levelers in place. H-20 D13-3 is 4' below grade w/riser. Round 18" concrete cover is 6" below grade. Marked w/4' stake. Unable to confirm as-built due to distance and trees. No sigh of high water staining over outlet inverts. Light root intrusion removed from outlet line at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" u Alarms in working order: ! ❑ Yes ❑ No* Comments (note condition of pump chamber, co4ition of pumps and appurtenances, etc.): * If pumps or alarms are not in working'order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Richard Leonard_ Owner Owner's Name information is required for every West Barnstable MA 02668 Au gust 3 2015 _� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 500 gal ea. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers located with camera, not excavated. Liquid level >1' below invert at time of inspection. No sign of past hydraulic failure. 4.5' below grade. No vent found. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert / Depth of solids layer Depth of scum layer Dimensions of cesspool — Materials of construction ` Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 21_75 Service Road — Property Address --------- ------------- --- ----- ---- Richard Leonard Owner Owner's Name information is required for every West Barnstable MA 02668 August 3, 2015 _� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): f: Materials of construction: i Dimensions i Depth of solids - f Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): / t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments N 2175 Service Road _ L Property Address Richard Leonard Owner Owner's Name information every is required for West Barnstable MA 02668 August 3, 2015 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately is >�JO - -- t> 0 �..: s.d+�e S } I5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address ------ ----------- --------- — Richard Leonard Owner Owner's Name information is required for every West Barnstable MA 02668 August 3, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: '5 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: 08/29/1999 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: maps.mass is.state.ma.us/oliver.ptip You must describe how you established the high ground water elevation: Engineered plans from 1999 determined adjusted high ground water at elv= 35. Base of SAS at elv= 61 per engineered plans. Accessed local ground water contours and topo mapping. No high ground water in area of stem. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/-3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road � Property Address ------------ --------- -- --- I Richard Leonard _ Owner Owner's Name information is required for every West Barnstable — MA 02668 August 3, 2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION o� (7 S Sys(J L 2 V,—Q, SEWAGE# VILLAGE(,J ASSESSOR'S MAP&PARCEL D I� ' NA &PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ize) Pk(� NO.OF BEDROOMS OWNER�IC�'v�,� acX 1_�©Y��,t•�C PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) I! Feet FURNISHED BY LA le o- �.��.�� • � rower � J !i.3/: 'JO1i FP! 13: 13 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health 0002/002 ri^N j- CERTIFICATE OF ANALYSIS Page: 9 + r Barnstable County Health Laboratory Report Prepared For.: Report Dated: 6/13/2008 Karl Soberger Order No.: G0846792 2175 Service Rd. j West Barnstable, MA 02668 F labor a to ry ID#: 0846792-01 Description: Water-Drinking Water Sample#: Sampling Location: 2175 Service Rd.,West Barnstable,MA Collected: 6/12/2008 i Collected by: Customer Received: 6/I212008 RESULT UNITS RL MCL Method# Tested f Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 6/12/2009 i>j�gf i' ND mg/L 0.I0 1.3 SM 3111 B 6/12/2008 ND mg(L 0.10 0.3 SM 311IB 6/12/2008 I sodiu:;r. 63 mg/L 1.0 20 SM 3111B 6/12/2008 ±'clal r,'_ol;'orm Absent P/A 0 0 SM9223 6/12/2008 • rcrld'+a-lance 280 umohs/cm 2.0 EPA 120A 6/12/2008 �r !. 7.6 pH-units 0 SM 4500 H-B 6/12/2008 sor.+i,era level is above the maximum contanunant level Those on a low sodiunc diet may wish to consult a p/lysi ;an. Approved By: (Lab Director) i j i i ! 9 1 I f ! I I 1 �I i I IND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable MA 02630 Ph: 508-375-6605 i ; i °F H^ CERTIFICATE OF ANALYSIS Pale: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 6/13/2008 Karl Soberger Order No.: G0846792 2175 Service Rd. West Barnstable, MA 02668 Laboratory ID#: 0846792-01 Description: Water-Drinking Water Sample#: Sampling Location: 5 Sei ice Rd. West Barnstable, — Collected: 6/12/2008 Collected by: Customer Received: 6/12/2008 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 6/12/2008 Copper ND mg/L 0.10 1.3 SM 311113 6/12/2008 Iron ND mg/L 0.10 0.3 SM 311IB 6/12/2008 Sodium 63 mg/L 1.0 20 SM 311113 6/12/2008 I Tctal Coliform Absent P/A 0 0 SM9223 6/12/2008 Conductance 280 umohs/cm 2.0 EPA 120.1 6/12/2008 PI-1 7.6 pH-units 0 SM 4500 H-B 6/12/2008 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physic!'an. Approved By: 6 /..r (Lab Director) � N ca , e r �r4 W � to ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Commonwealth of Massachusetts u w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road 1 01 Property Address Karl Soberger Owner Owner's Name ion is required for W Barnstable Ma. 02668 4/21/2008 equir every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Impor Whenfilling A. General Information When filling out � -:�• �r forms on the i computer,use 1. Inspector: �'i N c-1 only the tab key to move your Robert Paolini _ cursor-do not Name of Inspector t G use the return _ key. Ca ewide Enter rises,LLC Company Name •- r�. r� P.O.Box 763 Company Address Centerville Ma. 02632'. City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/21/2008 I spector's Signature bate The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. '"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 2175 Ser✓ice Rd.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 2175 Service Road Property Address Karl Soberger Cwner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 2175 Service Rd.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cw 2175 Service Road M Property Address Karl Soberger Owner Owner's Name information is squired for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection B. Certification. (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C Further Evaluation is Required b the Board of Health: q Y ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and.environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 2175 Service Rd.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M .2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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. 2175 Service Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts H w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 2175 Service Road Property Address Karl Sober e r 9 Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 :every page. City/Town State Zip Code Date of Inspection B.. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 11 ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ z The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 2'75 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for-signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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. El ® 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)] 2175 Service Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information 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 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d Well Water 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4/21/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 2175 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W.garnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance 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) J ❑ 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: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 2175 Serjice Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W.Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 14" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: . ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gallon Sludge depth: 18" Distance from top of sludge to bottom of outlet tee or baffle 14" Scum thickness 3 . Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 2175 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road M Property Address Karl Soberger Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑,other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 2175 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form ;i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Karl Soberger.. Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ N0 Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No J 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.): Box is Ievel.Box has 2 outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 2175 Sen.ice Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments °M 2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan,.excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500 LC ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching Chambers had 8" of water in them at time of inspection. 2175 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 2575 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2175 Service Road Property Address Karl Soberger Owner Owner's Name information is required for W Barnstable Ma. 02668 4/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. IV I I 'i:e,4 / eC,k ! ' • o �J�ScyK � CPkc� C h—d e.-5 tit t 2175 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2175 Service Road Property Address Karl Soberger Owner Owner's Name in required on for is required for W Barnstable Ma. 02668 4/21/2008 e1,ery page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Botttom of LC 40' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2/21/2001 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 Plate#2 annual ranges of groundwater elevations. 2'75 Service Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable . Regulatory Services SAMSPABM ; Thomas F. Geiler,Director prEo��A Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/25/2002 Order Number: G0218213 Karl H. Soberger 58 High Street Medford, MA 02052 Laboratory ID#: 0218213-01 Description: Water-Drinldng Water Sample#: 18213 Sampling Location�'2175 Service Rd;West Barnstable Collected: 11/20/2002 Collected by: Karl Soberger Received: 11/20/2002 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates <0.1 mg/L 10 EPA 300.0 11/20/2002 LAB:Metals Copper <0.1 mg/L 1.3 SM 311113 11/21/2002 Iron 0.4 mg/L 0.3 SM 3111B 11/21/2002 Sodium 22 mg/L 20 SM 3111B 11/21/2002 LAB: Microhiology Total Coliform Absent P/A Absent 307 11/20/2002 LAB: Physical Chemistry Conductance 140 umohs/cm EPA 120.1 11/20/2002 pH 6.6 pH-units EPA 150.1 11/20/2002 Note: Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems(taste, odor, staining)due to Iron. Sodium a bit above the average. Those on low sodium diet may wish to contact physician. Approved By: l� (Lab Director) t i f Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 No.------------------ --- BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion-*r Vell Conoructionpermit Application is hereby made for a permit to Construct (_), Alter ( ), or gepair ( )an individual Well at: ,p Location — Address /� ?�Assessors Map and Parcels Ze Owner Address — Installer.— Driller Ad ress Type of B ' wellin - — ----------_ ___—__ Other - Type of Building-- ------ No. of Persons-- ----- —_ T e of Well "'. A844�-- Ca acit Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Tcwn of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a C tificate of Compliance has been issued by the Board of Health. Signed - UL e l Application Approved By G -``" — _ � date Application Disapproved for the following reasons: date 3� Permit No.--;- b3�-L-� — Issued ---I !-�`—`--b- 112-- date 1 BOARD OF HEALTH TOWN OF BARNSTABLE C ertlf Irate ®f Compliance THIS IS TO CERTIFY, That the Individual Well ConstFucted j(-<Altered ( ), or Repairedby ( ) / In aller has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr(o�tectio _Regulation as described in the application for Well Construction Permit No. a a.rated—< 1 S9( THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector--- ----- — - iylc+,+�a..�i S e .. No. ---_-------—3 .r"'T' ry. Fee------ ---- BOARD OF-HEALTH TOWN 0 : '"' BARNSTABLE Appiicat ion-for Vel[ Con0ruct ion Permit Application is hereby made for a permit to Construct (Alter ( ), or Repair ( )an individual Well at: Location Address Assessors Map and Parcel Owner Address — 'I, _---___----7 —(—//f/------- -- _-------------------------------Installer Driller— Driller Address Type of Dtellurg� Other - Type of Building-- --_ No. of Persons— -------------_- T e of Well--��— /�=------ Ca acit Purpose of Well— — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board'of Health. Signed - -- — '—`` - Application Approved By ---- date Application Disapproved for the following reasons: -------- - ----- --- -- —date Permit No. \� Issued----- - r date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate ®f Compliance a THIS IS TO CERTIFY, That the Individual Well.Constructed.(-"r Altered ( ), or Repaired ( ) ------------- ---------- --- 1 In to ler ` has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.��? =`-Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell Construct ion Permit No.--- ---- Fee --- Permission is hereby granted —�---- ----------- to Construct Alter ( ), or Repair ( : ) an Individual Well at: . NO. Street -` --- ---- / t as shown on the application for a Well Construction Permit _ No.- C22' ' Dated. —� � '� - . s _ -- Board of Health-----_-----_-----------'-- .. `DATE CERTIFICATE OF ANALYSIS page: 1 �U tad Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/19/2002 Bayberry Building Co.Inc. Order Number: G0218031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID##: 0218031-01 Description: Water-Drinking Water Sample#: 1803101 Sampling Location: 2175 Service Rd W Barnstable MA Collected: 11/04/2002 ollected by: E Meehan Received: 11/04/2002 Routine ITEM RESULT UNITS MDL MCL Method# Tested LAB: IC Lab Nitrates <0.1 mg/L 0.1 10 EPA 300.0 11/04/2002 LAB: Metals 'Copper _. . _.. ... .__ ......__.. w:,._<0.1 •- mg/L.,.__.._0,1 . 1.3.__ SM 3111B 11/12/2002 Iran 2.5 mg/L 0.1 0.3 SM 3111E 11/12/2002 Sodium 19 mg/L 1.0 20 SM 3111B 11/12/2002 LAB:Microbiology Total Coliform Present 9 P/A 0 Absent 307 11/04/2002 LAB: Physical Chemistry Conductance 238 umohs/cm 1 EPA 120.1 11/04/2002 pH 6.7 pH-units 0.1 EPA 150.1 11/04/2002 Note: Recommended maximum contamination level exceeded due to Coliform Bacteria.Retesting is recommended.Water may also present aesthetic problems(taste,odor,staining)due to Iron. RECEIVE® ZOOZ 1 TOWN OF BARNSTABLE.. l HEALTH-DEPT. B 7 j Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-317 -6605 t 0j79' CERTIFICATE OF ANALYSIS '� Page: 2 lu- Hi i Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/19/2002 Bayberry Building Co.Inc. Order Number: G0218031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID#: 0218031-02 Description: Water-Drinking Water Sample#: K533 Sampling Location: 2175 Service Rd W Barnstable MA Collected: 11/04/2002 ollected by: E Meehan Received: 11/04/2002 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS MDL MCL Method# Tested LAB: GUMS 1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,1,1-Trichloroethane BRL ug/L 0.5 200 EPA 524.2 11/15/2002 1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 1,1-Dichloroethane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,1-Dichloroethene BRL ug/L 0.5 7.0 EPA 524.2 11/15/2002 1,1-Dichloropropene BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 524.2 11/15/2002 1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2-Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2-Dibromoethane(EDB) BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 11/15/2002 1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,3,5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,4-Dichlorobenzene BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 11/15/2002 4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 11/15/2002 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph 508-375-6605 t CERTIFICATE OF ANALYSIS Page: 3 g9 'J Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/19/2002 Bayberry Building Co.Inc. Order Number: G0218031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID#: 0218031-02 Description: Water-Drinking Water Sample#: K533 Sampling Location: 2175 Service Rd W Barnstable MA Collected: 11/04/2002 ollected by: E Meehan Received: 11/04/2002 Benzene BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 Bromobenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Bromochloromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Bromodichloromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Bromoform BRL ug/L 0.5 EPA 524.2 11/15/2002 Bromomethane BRL ug/L 0.5 EPA 524.2 11/15/2062 Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 11/15/2002 Chloroethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Chloroform BRL ug/L 0.5 EPA 524.2 11/15/2002 Chloromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 11/15/2002 cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 11/15/2002 Dibromochloromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Dibromomethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 11/15/2002 Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 11/15/2002 Isopropylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Methyl-tert-butyl ether BRL ug/L 2.0 EPA 524.2 11/15/2002 Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 n-Butylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 n-Propylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Naphthalene BRL ug/L 0.5 EPA 524.2 11/15/2002 p-Isopropyholuene BRL ug/L 0.5 EPA 524.2 11/15/2002 sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Styrene BRL ug/L 0.5 100 EPA 524.2 11/15/2002 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 4 Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/19/2002 Bayberry Building Co.Inc. Order Number: G0218031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID#: 0218031-02 Description: Water-Drinking Water Sample#: K533 Sampling Location: 2175 Service Rd W Barnstable MA Collected: 11/04/2002 ollected 5y: E Meehan Received: 11/04/2002 tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 Toluene BRL ug/L 0.5 1000 EPA 524.2 11/15/2002 Total xylenes BRL ug/L 0.5 10000 EPA 524.2 11/15/2002 trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 11/15/2002 trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 11/15/2002 Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 11/15/2002 Note: Approved By: (Lab Director) IZclZaoZ Superior Court House, PO.Bog 427, Barnstable, MA 02630 Ph: 508-375-6605 i NOU-22-2002 09:55 15083627103 15083627103 P.06 y of as ,s CERTIFICATE OF ANALYSIS Page 1 MSM4V PIP Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/I5/2002 Bayberry Building Co.Inc. Order Number: G0218118 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory III#: 0218118-01 Description: Water-Drinking Water Sample#: 18118 Sampling Location: 2175 Service Rd..Barnstable Collected. 11/13/2002 ollected 'by: Realtor Received: 11/13/2002 Test Parameters ITEM RESULT UNITS MDL MCL Method# Tested LAB: Microbiology Total Collform Absent CFU/100mL 0 0 P/A 11/13/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: u�-•---� (Lab Director) Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 . 1 �. NOU-22-2002 09:54 15093627103 15083627103 P.02 OF CERTIFICATE OF ANALYSIS page CHU $ Barnstable County Health Laboratory Report Prepared For- Report Dated: 11/19/2002 Bayberry Building Co.Inc. Order Number: G0218031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID#: 0218031-01 Description: Water-Drinking Water Sample N: 1803101 Somplin¢Location: 2175 Service Rd W Barnstable MA Collected: 11/04/2002 oilected by: E Meehan Received: 11/04/2002 Routine ITEM RESULT UNITS MDL MCL Method# Tested LAB: IC Lab Nitrates <0.1 mg/L 0.1 10 EPA 300,0 11/04/2002 LAB: Metals Copper <0.1 mg/L 0.1 1.3 SM 3111B 11/12/2002 Iron 2.5 mg/L 0.1 03 SM 3111B 11/12/2002 Sodium 19 mg/L 1.0 20 SM 311113 11/12/2002 LAB: Microbiology Total Coliform Present P/A 0 Absent 307 11/04/2002 LAB:Physical Che►nisay Conductance 238 umohs/cm 1 EPA 120,I 11/04/2002 PH 6.7 pH-units 0.1 EPA 150.1 11/04/2002 Note: Recommended maximum contamination level exceeded due to Coliform Bacteria.Retesting is recommended.Water may also present aesthetic problems(taste,odor,staining)due to Iron. Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph:509-375-6605 NOU-22-2002 09:54 150e3627103 15083627103 P.03 V.>4 CERTIFICATE OF ANALYSIS page z $ Barnstable County Health Laboratory �,�. Report Prepared For: Report Dated: 1 111 9/20 02 Bayberry Building Co.Inc. Order Number: G0219031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID#: 0218031-02 Description: Water-Drinldng Water Sample#: K533 Sampline Location: 2175 Service Rd W Barnstable MA Collected: 11/04/2002 olleeted by: E Meehan Received: 11/04/2002 EPA 524.2- Volatile Organics by GCMS ITEM RESULT UNITS MDL MCL Method# Tested LAB: GCIMS 111,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,1,1-Trichloroethane BRL us/L 0.5 200 EPA 524.2 11/15/2002 1,1,2,2-Tetrachloroethane BRL ug/L 0.5 FPA 524.2 11/15/2002 1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 5242 11/15/2002 1,1-Dichloroethane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,1-Dichloroethene BRL ug/L 0.5 7.0 EPA 524.2 11/15/2002 1,1-Dichloropropene BRL ug/I- 0.5 EPA 524.2 11/15/2002 1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 5241 11/15/2002 1,2,4-Trimethylbenzene BRL ug& 0.5 EPA 524.2 11/15/2002 1,2-Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 11/15/2002 1,2-Dibromoethane(EDB) BRL ug/L 0.5 EPA 524.2 11/15/2002 122-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 11/15/2002 1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 1,3,5-Trimethylbenzene BRL ug/l. 0.5 EPA 524.2 11/15/2002 1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 11,4-Dichlorobenzene BILL ug/L 0.5 5.0 EPA 524.2 11/15/2002 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 11/15/2002 2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 11/15/2002 4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 11/15/2002 Superior Court House, PO.Bog 427, Barnstable, MA 02630 Ph: 508-375-6605 NOU-22-2002 09:54 15083627103 15083627103 P.04 ~ o Page: 3 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 11119/2002 Bayberry Building Co.Inc. Order Number: G0218031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID it: 0218031-02 Description: Water-Drinking Water Sample#: KS33 Sampllne Location:_ 2175 Service Rd W Barnstable MA Collected.• 11/04/1002 ollected by: E Meehan Received: 11N4/2002 Benzene BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 Bromobenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Bromochloromethane BRL ug/L 015 EPA 524.2 11/15/2002 Bromodichloromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Bromoform BRL ug/L 0.5 EPA 524.2 11/15/2002 Bromomethane BRL ug/L 015 EPA 524.2 11/15/2002 Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 11/15/2002 Chloroethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Chloroform BRL uglL 0.5 EPA 524.2 11/15/2002 Chloromethane BRL ug/L 0.5 EPA 524.2 11/15/2002 cis-1,2-Dichloroethene BRL ug/L 0.s 70 EPA 524.2 11/15/2002 cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 11/15/2002 Dibromochloromethane BRL ug/L 0.5 EPA.524.2 11/15/2002 Dibromomethane BRL ug/L 0.5 EPA 524.2 11/15/2002 Dichlorodifluoromethane BILL ug/L 0.5 EPA 524.2 11/15/2002 Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 11/15/2002 Hexachlorobutadiene BRL uSIL 0.5 EPA 524.2 11/15/2002 Isopropylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Methyl-tert-butyl ether BRL ug/L 2.0 EPA 524,2 11/15/2002 Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 11/15/2002 n-Butylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 o-Propylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Naphthalene BRL ug/L 0.5 EPA 524.2 11/15/2002 p-Isopropyholuene BRL ug/L 0.5 EPA 524.2 11/15/2002 sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 11/15/2002 Styrene BRL ug/L 0.5 100 EPA 524.2 11/15/2002 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph:508-375-6605 NOU-22-2002 09:55 15093627103 15oe3627103 P.05 CERTIFICATE OF ANALYSIS Page.- 4 CUP VP Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/19/2002 Bayberry Building Co.Inc. Order Number: G0218031 Jaques Morin 1597 Falmouth Rd. Suite 4 Centerville, MA 02632 Laboratory ID#: 0218031-02 Description: Water-Drinking Water Sample#• K533 $ampiing Location: 2I75 Service Rd W Barnstable MA Collected: 11/04/2002 ollected by: E Meehan Received: 11/04/2002 tert-ButylbenZene BRL uSiL 0.5 EPA 524.2 11/15/2002 Tetrachloroethene Bn uE/1. 0.5 5.0 EPA 524.2 11/15/2002 Toluene BRL ug/L 0.5 1000 EPA 524.2 11/15/2002 Total xylenes BRL ug/L 0.5 10000 EPA 524.2 11/15/2002 trans-1,2-Dichloroethene Bn ug/L 0.5 100 EPA 524.2 11/15/2002 trans-43-Dichloropropene BRL ug/L 0.5 EPA 524.2 11/15/2002 Trichloroethene ]an ug/L 0.5 5.0 EPA 524.2 11/15/2002 Trichlorofluoromethane BU ug/L 0.5 EPA 524.2 11/15/2002 Vinyl chloride BRL uF/L 0.5 2.0 EPA 524.2 11/15/2002 Note: Approved By: (Lab Director) !I Z Ohoo Z Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 505-375-6605 05/21/2002 06:32 5088336359 R J BEVILACQUA CO PAGE 06 011" *_' �,�—'- IC,a7p, t;vim„ r"t•�B�►G •--•�'�^' �,• •�.-:' '. tti .. 4z, - •'•-•: .y• t.•!..`i. � - - ->.�'!J',•.' :.9 f v'{•.tiwT1W ..� .A ° �` .t�....,, f y_ -.�' ..tea; - ;•��";•'•. •�• J 1C� i 3• �•°': �a .; '3• ... ... .+... ti , ?�iQV •+ .. �' ~'- :Fr:.:'�r•a,.i•:.i�s�•1 f �Te�i� .'vi},'.,s;•.t-- . • i. .fir'• 1 .�'�•a. 'i '``" :�,,1 . Y .;. T',:.•,- • � %Lh'.ZV#pi,� T�+. �I !3•- ,�F. f`••• .� ;•,,^ -� r 1_V 0.y f�✓`.�t'S'° :�j p'=��d: „a..�'W°� i. a Ste• .t �•. � ••'�.'•�,e. :i� ., t•�t i� �. z•• �'�� : �a _+.. r . •. . - . • �'• µme,♦� ,,{.-,.•v,P _ g >g� .k.� 0r. I ... 1:'f=sue ..r li,�` �f"'• .;.R.. .� i ♦ R r•�. {`.e• '•�4. • �� l` � y� -' i K'': •!`,obi y �`.J.�'•'V.y ewe' / . •�. �}" .'', _ .'�-�.+., F:4', �✓�::., {:•• g a+? �90.r apt •y :,, 1 � +..ate. a. ._.. ...rr.^ •r o+ .• ^ .'i.. :Yi f3•..^V. :•L .oar. r.Yuq..� (. ••; ,-s'• :•t••d . .r:9{�TO ainwr.f•w.yt i v.. - %t. 'irr`.' .g.,' a ..rt'-5' t..'+C*ii,�.`. �•j:w.,�,,,;. N i 4 • '"i` •7r.. `.•vas».~.�:t+.:.�•.�'."S:. i� s , 4'�.'•mow C.'.'.'R�•."..p •j•,�''�' /� BUIL/���NOTICE t,, D'for .rrpy _ ..._ ..._.-...._.-..___..��_,...._._..._-cn _ __ _.._• .._ - - - __.___...._.-..a.._..._.._....._..._.._..-....... co Lo 00 Jt w4w r(i't '`J� • 'r :� K.+ 'bJ4atN0 oyes Lo 04 •` � � � e.2 ; . !. tn vMk .. 2•i i • aSY fr 4. TOWN OF BARNSTABLE LCiCATION 2 5 SefYi Cf_ �' OCLa sl WA E # � VILLAGE) . ASSESSOR'S MAP & L� U 7� INSTALLER'S NAME&PHONE NO, �� V!�Q�CIIS.Q.�dO1�SYt1C>i�� SEPTIC TANK CAPACITY 1 J OO Q CL� l rfTY-t� roo y / II r LEACHING FACILITY: (type) yC�G✓b/l� s ize) /? NO.OF BEDROOMS BUILDER OR OWNER 0.. PERMITDATE: 3. uo' O COMPLIANCE DATE: 7-Lhl 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 6 � _ 16 a5ur ow MCA c A- h w5 3 s No. Y � Fee ' �0 / w' Entered in computer: y THE COMMONWEAIQTH OF MA HUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2[ppYication for izpooal 6potem Construction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L b '3P. Owner's Name,Address and Tel.No. a.t W'' s;� •4� cZ� A P}�6s Map/Parcel Installer's Name,Address,and Tel.No Designer's PSE ;p ddiags 4 TgD01YLE & ASSOC. 42 ,`:.;: ^bury La_ae w Ea�I: al—mouth, MA 0,'r,36 Telephone- 50 h Type of Building: we lin No.of Bedrooms '3 Lot Size 0 -L- sq.ft. Garbage Grinder( ) Type of Building No.of Person§ Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 t7 gallons per day. Calculated daily flow gallons. Plan Date b L z(.- e l Number of sheets Revision Date Title 5\ L Atv h. S /s L = na ►'� Size of Septic Tank l<to.O a Type of S.A.S. i Description of Soil 5\,i'r� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agreeNissued jis Edo n and maintenance of the afore described on-site sewage disposal system in accordance with the provisirah. d&X; o and of to- dceje,s/y/s�t in operation ntil a Certifi- cate of Compliance has beene Signed to L& Application Approved by Date ,,IS / Application Disapproved for the following reasons Permit No. Date Issued `-No. Fee ITHE.COMMONWEAf TH vPl= A SA HUSETTS Entered in computer: t u ,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS,, Yes ' � rfcatiori for i�poal *potem Cow5truction Vermtt -:�.vApplication for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ' Location Addddres L�No. L o '3 P, Owner's Name,Address and Tel.No. ' Assesso�s Map/Parcel �S j�� �� `,/�e A/ q, Aft}o f J✓ Installer's Name,Address,and Tel.No. Designer's N d el. 3. LSbYLZ & - `� ) 42 ('a- .t-�_-burY La-ie •. � Eas i Falmouth, vi�. • .. 25 Type of Building: awc�Jlin No.of Bedrooms 3 Lot Size 1ZZ sq.ft. Garbage Grinder( ) Type of Building No. of Persons % Showers( ) Cafeteria(. ) Al Other Fixtures _ ' Design Flow 3 3 0 gallons per day. Calculated daily flow 3 gallons. Plan Date b Z - 'L C.- c�l Number of sheets Revision Date Title S�TV- t, N '�✓Ph. S�ri ��_ .,FoVt "� mrz- Description Size of Septic Tank 1'�an "L • Type of S.A.S. c.l�aH of Soil � Nj� 1; M NAture of Repairs or Alterations(Answer when applicable) � 1 y Date last inspected: Agreement: The undersigned agrees the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisionNSTtle A the Environment o and oft lice a syste in operation ntil a Certifi- cate of Cem liance has been iss Board of Hea . p .v� Signed ate Application Approved by Date > d 77-7 Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CET , that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by -S at I J A c-L-- V01L d � �6 l- has been constructed 'n accordance with the provisions of Title 5 and0e for Disposal System Construction Permit No. 2001 / /" dated o ' Installer ���t1P5 M 0,, Designer -The issuance of s pqrmit shall not'be construed as a guarantee that the systW will function as de geed. Date :7 (� Inspector No. �"�y.l °M - -- Fee 00) THE COMMONWEALTH OF MASSACHUSETTS a\ PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Diopogar *pgtem Com5truction Vermtt Permission is hereby R ranted to Construct( )Repair( )Upgrade( )'abandon( ) System located at f '"� tl�k"66 _, 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 Kermit. �Date: //0 /0/ Approved by r TOWN OF�B�ARNSTABLE G (L. LOCATION 2 �rJ SAC L _ !�(3t7.3.7► SEWAGE # � VILLAGE ASSESSOR'S MAP& L� v�� INSTALLER'S NAME&PHONE NO. • • tTt U�l• 'tti SEPTIC TANK CAPACITY 15 Qfl LEACHING Ft CILITY: (type) �0 6A f ly,, Lrnk l size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 3' 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 LXfie J3 i /Yo�-sic °if e-ICh i I e r 4 vp�tvsf.•si. -� t d:•.r:: �'Ia.. -iri :�'%� 'S y.a '.�%iC; y1( r'` • ,f, tt ,d... 'ter ^t. - sf. c` •t ,n •4. •r 1' w rt i C7 ,• V. s ''a•' r. f.,i s DUO : 1 NICE 4. t 1 •t r`.e t:f�S11��R �lf W -� -..�__-r--.� ...:�.,¢,,,.. d • � tlrs. tot f +!W. :•'.•. � � .. •.:,- _ '. r. �H• H' cnCD OD I 1 S is -- • - ...._„__,„_. � .r o' �I - 4� m ! 04 t4•'.a'.+s c N Vw Its•.+ ,,.. . Rh tkyy o• - „' N t r• r 8� e F 1 -- sa _ - I t t. T� i j 2" of 1/8„ - 1/0" Peastone - TOP FOUND. EL. 'Z 3 ;: .•• .__ •f . -o - °eon •.'. - O . A Ozoo GO o2--ol low LA7-r�&_ _ WA•n-R 'nct1T COVER - Total Trench Length ?� Trench �dt 13. 32 INV. EL (,t;'• _- 2 BEVEL FLOW LINE 3114 - 1-1/2" Washed Crushed Stone 3/4" - 1-1%2" Washed Crus ed Stone 6 0� 0 R 1cr MIN. I,q,+ INV, EL. b -----� -� r ' �` oo°0 PROPOSEDENCH SECTION o r� S. A.A S. 1-4 �, R i INV. EL. suMr' � SER�O� — 10� MIN. 416 UDUID DEPTH o °o d o 0 r 0 a o c� o oo� _ INV. EL. In .L'1. c,3,o 08 ° ' , WATER °0D TOWER El. G1.0 SHOOT FLYING HILL RD. , INV. EL (AA,3 " Trenches No. of —1—_ No. of 500 Gallon Precast Chambers �- b• wEQUAQu ET LAKE PRECAST RE NFORCED C0i',1CRETI= 3/4" - 1-1/2" Washed Crushed Stone 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK DISTRIBUTION BOX. EL �4,o LOCUS MAP SCALE: 1" = 2000' L_ ' MINIMUM CONSTRUCTION MATERIALS Pr"R 310CMR 15.226(2) INSTALL ON A LEVEL BASE MINIMUM WALL THICKNESS 2" TEES SHALL BE COtdSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6". ABOVE THE FLOW LINE MINIMUM INSIDC DIMENSION 12" OF THE SEPTIC TANK' AND BE ON THE CENTERLINE OF THE _. SEPTIC TANK LOCATED DIRECTLY UNDER THE CLEAN-OUT OUTLET' INVERTS SHALL BE EQUAL 10 EACH MANHOLE OTHER AND AT 2" MINIMUM BELONG INI-ET INVERT. THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2' NOR THE DISTRIBUTION LINES FROM 111E DISTRIBUTION L30X MORE THAN 3" ABOVE THE INVERT ELEVATION OF THE SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING ZED_ OUTLET PIPE. THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTT.IDUTIO"d � �� �� LINE INVERT AFTER ALL LINES HAVE BEEN SEALED IN PLACE. INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE AND NON-DEFORMABLE MATERIAL PERMANENTLY FASTF_ND TO THE pC}�as�tj ��rLl. ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY LINE OR RECONSTRUCTING THE LINES IJN71L ALL INVETS ARE OF COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE EQUAL ELEVATION. HAS BEEN PLACED TO ENSURE STABILITY AND TO PREVENT Access & Utility Easement - ed e of a ve edge of a Le •�' --- ---------P------ --- -------- -__------1'----------------------- ----edge °f SETTLING ---__------ - 11_8_-_- - - _ - _ - - _ _ _ _ _ _ _ _- - ----- _ _- ------- Top CB El. 122.35 - 11 - - - ___ - 1,2.2 \ - - Pa ve BM. Top 6' - - - - - - - - - - - - - - - -- - - - - - - -- -------- A MINIMUM COVER OF 9 _ _ _ _ - - - - - - - - - - - .... EATIC TANK. SHALL H G VD _ ..._- .. _ 11g 1Zg 2¢ \ - - - - - - - - - - .. THREE 20' MANHOLES WITH READILY REMOVABLE IMPERMEABLE 112 _ _ _ _ __ _ _ ,_ . '\ 150.00 ` _ _ _ _ _ _ ' i 11g _ - Il - - - - COVERS OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS `S - 0 2 I0g '.s�0� �`.` ���sl?gl ` ,\ \� \� � �1•�9 150.00 114 - PORTS SUNG PLACED AT THE CENTER AND OVER THE INLET AND OUTLET TEES. Oat _ \\ \ \ 11g \1'(• _ `- / // 1 J _ 1' ' ` WITH GAS BAFFLE. 'G - rt•t �,� -2 . 1p_ 1 E SHALL BE EQUIPPED _ - THEOUTLETTE � \ � � � • � - _ _ _ _ - -' _ _ _ - _ _ 1 • _. 0't, � _ '• �- ' �' - .moo , � . 011 , �\ ` L _ , ` 104 - - - - - - - - - - - -10p 1, joei Xj i ii - - - - - - - - - - - - - - -- - _ _ _ _ - - - 6 GENERAL CONSTRUCTION NOTES v�� ti.� -04 - - ' LS �'�'OTL. '// - - _ - _ - - -- - - - (9 - 'go °L`l` 10�� `100 5 REP.LICE SOI 5 'i 'i f l l� 9g __ B ti5o e •,r - i 1. ALL WORKMANSHIP AND I IA IL-RIALS SHALL CONFORM TO D.E.P. TITLE 0 _ - ONS FOR � � - �' 0� 0 i ,ii :..` � � _ - - -.- - 6 � •• `. ,,r9, '0 �- • AND THE TOWN OF _ �Y�'rL� RULES AND REGULATIONS REMOVE UNSUITABLE SOILS FYlT FELT LAT RALY ` _ _ _ _ _ _ _ — _ _ - ONS BEYOND TEE OUTER PERIMF.TER Qti i / ' 2�1 _ - - - - - - - - - - B4 - . oy,, 6� r _ l _ _ - _ g THE SUBSURFACE DISPOSAL OF SEWAGE. IN ALL DIRECTI 0 OF THE SOIL ABSORBTION SYSTEM TD THE DEPTH OF - - .'rtz f PORT OVER TANK TEES SHALL BE ACCESSIBLE ALLY OCCURING PERVIOUS MATERIAL AS REQUIRED �;� i/ / ;i/ /� / - _ _ - _ - - _ _ _ 80 8z` �,9c� - - - _ _ - 6g _ 2. AT LAST ONE ACCESS P NATURALLY / / / � _ - � � � _ , WHITHIN SIX INCHES OF FINISH GRADE WITH ANY REMAINING ACCESS BY 310CXfR 15.240 AND RELACF, WITH CLEAN GRANULAR / - - - - - - - - - - - - PORTS BROUGHT TO WITHIN TWELVE INCHES OF FINISH GRADE. SAND, FREE FROM ORGANIC MATTER AND DELETERIOUS P •�, y0 , vi / l l ll /l l � l ► � - - - - - -�,z• �� � � � � � - � s • - _ • SUBSTANCES F E SANITARY SYSTEM SHALL BE CAPABLE OF �� Ip0 i� l l l `;l l l l l zo 3. ALL COMPONENTS 0 TH _ �C a� _ 80 UNLESS THEY ARE UNDER OR WITHIN 10' �' / / / / / / _ /O - _ - _ - - - ~ o - WITHSTANDING H 10 LOADING J i / l / I l I ` _ WIT}-i I N ,4 '' � . � � � _ 64 � ,g �°c'•,¢` c�ii o _ g0 , - OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR p 96, i / / / / l ��82g 1), 68 51 ti �t. Iq _ Ar.bole - a T8 10 OF DRIVES OR PARKING UNLESS NOTED. - 4. THE EXCAVATOR CONTRACTOR SHALL VERIFY THE LOCATION OF ALL �� `96', / � \ I I I I � � � \ � �°lf _ 'y'ti � � \ •0 ' eta'• l - 1500 �d _ n _ y6 _ - SITE UTILITIES PRIOR TO ANY EXCAVATION. I �� 9 _ Zoning District.• RF' " 0.02 SLOPE. ,y�J � • � °S,e \ i I ► I 16'0 0� � pl, 96 � ° - - ,�� -0 �. _ -'_ _ _ _ - 5. SEWER PIPES. SHALL BE 4 SCHEDULE 40 PVC LAID AT pr°P y�aY , i II I ' ' III 1�°�°Osed �e �0 , �� • ,e lace soil \ °° "I 35 o��� 92, ` \ Driye;� ' ►' i I i I II II II 6B \ \\ T$oaf `�' - 6g_ r0 p- Overlay District: GP 6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE Note: Should soils be encountered during installation of sewage system the are o'o I I I i 1 I I - MORTARED IN PLACE. 0� 90 o I I ` 64 � _ _ _ vn� l °� � not consistent with soil logs, contact the designer and/or your local Health Department �� i I I T - 66 \ / / / 0� Building' Setbacks: V A MINIMUM SLOPE OF 0.02 FEET PER FOOT. before proceed inc. aB 'N `z2 r offs o / I I i I \ T2 t o�o _ _ I l l l Res �p l 25 Side Front150' 7. FINISH GRADE SHALL HAVE LQ Q, 1 I , I I I 1 I \ \ \ se 64 r I, 86 y \ / A1,��ose o ` 0 (941 I ` \ `5p122 \ l l 1 1 S' ; ° 84 _ - - I ► SQf �� l / I `�s' Assessors Data: ztg-�� _ lies - _8� _I g0 \ ` ` \ \ , l ` , _ _ - �' FEMA Data: Zone -C., 66 o 11 199.14 - RePlac _ _ "� ` _ prop osed- S A.S _ - N657840"E 175.34 B ` 3 _ _ , SOIL OBSERVATION DATA: - 1 � - DESIGN DATA: ` - ' ` ` 6g ` _ 1 M • r /�!,( — may — N 04 -z - STRUCTURE ` u - ��' ----------------- ------ i TEST DATE 8 L "\ _�7w 11�.1C� TYPE NO. BEDROOMS GARBAGE DISPOSAL �2 ` ----- Q. s• -pov>~Y ---- -- -------- SOIL EVALUATOR ------------- - DESIGN FLOW 181.61 a d � �� "'s o "i? a tom' i S6518'40„j� B.O.H. AGENT 0 Cape & TYneyard Ele . 1'gsement o� SITE PLAN OF LAND IN -r� WE'S T BARNS TABLE' PERC/RATE 0- --3n-0 0 Lod Z f`1�.W�ot>, �.1�. SEPTIC TANK - y�`F 1�0� ��-a�, bhp r rr -�� --Z - �DI�_ "�.ThoRhla-P1 P L 1:.1►CL C ZML�. Prepared Forr o�t a LEACHING FACILITY A �,jH of A,4s BA YBF,RRY BUILDING COMPANY SIX. \o t u h sL toY�-1/Z S�. IOHR. ` l-LGlSiE1Pf f"c (, 4 4 wo Pt ° y�t - �µ oFf ��� Depicting �_$ z W `9"1 ,L `z' �F1= gyp= "g \' a. " 5 Y �(, i a STEPHEN r �\ � �ss-0 s� goy 4 \e`i� '+� 30'' _ 24kk s y � ,. �; z� flo LE V`I n' G RAT' C SCALE • _ `t �1e-Z�. Q -r� 3 S LQ L uCA1. r..�S�c.r,► _ ` - �t` Igo. 375 _ � � wILLInM r' L---- � C( �1Et� 5y� Z•'��� �'�A �t0 "t TALsr -\ gti7iy ^� �Z. ��, LIERERMAN 0jo 40 - 0 --- 20 40-- ------00 180 �1l;SS•;}� Ilk' 1391 se�D GO'+ .�o ,,. i~iHC ��( ��L v,�;; A „o n .. Scale: As Shown Date: 02126101 I ti' .pO CZ N - � .s'�`c'3 ��.-co st��*..354.. ���,�; ,•.•,�,;..;:=� �,� - 1tc,�' — -------- Prepared B . C 1'1� -1slIL4) _ l j�� �nM c Y IP Y' Z. ��S� y�3 \���n► I ' ) Stephen % Doyle and Associates +� IN FEET 54%1to 1 inc:, = 40 it. 42 Canterbury Lane, east Falmouth, MA 02536 - _ -5.0 0 1 �_11041I Telephone: 508/540-2534 CW6ou'�•1TtstL�� '2�-�: . a'z-z.Fy•-c�\ �'t7p �'� 9'1Z3 _ ---- ---- - ---- --- -----_ - o a_ I,)- Wt _!w --