HomeMy WebLinkAbout0404 MARSTONS LANE - Health 404 Marstons Lane
Barnstable P
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COMMONWEALTH OF MASSACHUSETTS,
3 = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
> dDEPARTMENT OF ENVI RONVEN TAL .PROTECTION
� C@ � �7M � D
DEC ` 7 2004
HEALTH DE-PT
TITLE5 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A _.
CERTIFICATION �RCF1.
t A
PropertyAddress:
,1 Y G l 3
i -. —r�
/ Owner's Name
Owner's Address: „ �- aa
CD ...
Date of Inspection:
Name of Inspector:(ple se print) ZaAG .
Company Name: imw
Mailing Address: ( .f , ,71 _
u�ay �}
c y.�Z� .
Telephone Number. J��
CERTIFICATION STATEMENT
1 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:`
t' Passes
Conditionally Passes
-Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: d- Date:
The system inspector shall subm' a copy of this ins ection report to the Approving Authority(13oard of Health or`
DEP)within 30 days of completi g this inspection.If the system is a shared system or has a desi jn,flow of]opo.;
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority. '
Notes and Comments
. .A. v
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I _
' r
Page 2 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 140T m4k4s�eNS
T�M 0O K% OP Je- A 14
Owner:.
' Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
" I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 1]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) .
Property Address: ZT %��3C' sue►
Owner: T-6�.'Olt z X1.t2
Date of Inspection:
C. Further Evaluation is Required by the Board of Health: ti
Conditions exist which require further evaluation b he Board of Health in order to determine if the system
is failing to protect public health,safety or the environm t.
1. System will pass unless Board of Health drmines in accordance with 310 CIVIR 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 Boar&of Health(and,,Public Water Supplier,if any)determines that the. .-
system is functioning in a manner that protects th' public health,safety and environment:
The system has a septic tank and soil ab orption system(SAS)and the SAS is within 100 feet of a
surface water supply,or.tributary to asurfa e water supply.
_ The system has a septic tank andf AS and the SAS is within a Zone 1 of a public water supply.
_ The system has aseptic tank,and SAS and the SAS is within 50 feet of.a private water supply well.
The system has aseptic 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,performedat a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than'5 ppm,provided that no other.
failure,criteria are triggered.A copy of the analysis must be attached to.this form;
3. Other: .
3
Title 5 Inspection Form 6/15/2000
r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:TU ki!/L�
Y eGllrQ�-�i�„
Owner:
Date of Inspection: ir r
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
charge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
cjlpgged SAS or cesspool
— tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
- _-Zce pool
r'd depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
0'times pumped 0
t/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
�ater supply.
ny portion of a cesspool or privy is within a Zone l of a public well.
_ a�nny portion of a cesspool or privy is within 50 feet of a private water supply well.
--VA y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a lar system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate e' er"yes"or"no"to each of the following:
(The following cri ria apply to large systems in addition to the criteria above)
yes no
the ystem is within 400 feet of a surface drinking water supply
e 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 yo 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of l]
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST `
Property Address: L o 0�' 'S
Owner: e-0 Cj
Date of Inspection: i f —0 i� r
Check if the following have been done.You must indicate"yes".or"no"as to each of the following;_
es Y ' • . �` ''
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?,
- l!— Has the system received normal flows in the.previous two,week period-?.
L' 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 backup'?
-Y� '
TWas the site inspected for signs.of break out?
Were all system components,excluding the SAS,located on site? R
Were the septic tank manholes.uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?,
Was the facility owner(and occupants if different from owner).provided with information on the proper:
maintenance of subsurface sewage disposal systems .
The size and location of the Soil Absorption System(SAS).on the site has been determined based on:
Yes —
Existing information.For example,a plan at the Board of Health. ,
Determined in the field(if any of the failure criteria related to Part G is a6ssue approximation of distance
is unacceptable)[31�0 CMR 15.302(3)(b)]
y Title 5fInspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:—I/O
Owner:
Date of Inspection: �rf —0 5�
FLO CONDITIONS
ONDITIONS
RESIDENTIAL
Number of bedrooms.(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current-residents:
�'Doe'�dence ha_v_e a_garbage grinder(yes or no)'
llel
I's-laundry o esan parate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):JW
Water meter readings,if available(last 2 years usage(gpd)): an �G�fy
Sump pump(yes or no):
Last date of occupancy:na 010•`�(/
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 MR.15.203): gpd
Basis of design flow(seats/ ersons/sgft,etc.):
Grease trap present(yes o no):
Industrial waste holding t nk present(yes or no):_
Non-sanitary waste disc arged to the Title 5 system(yes or no):_
Water meter readings,i available:
Last date of occupanc /use:
OTHER(describe):
GENERAL INFORMATION.
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):W
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE SYSTEM
eptic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool '
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of.all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):AD
Title 5 Inspection Form 6/15/2000 6
I
Page 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address AA
Owner: i _"A
Date of Inspection:
BUILDING,SEWER(locate.on site plan) r
Depth below grade:
Materials of construction:_cast iron Z4OVC_other(explatn).
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ocate on site,plan)
Depth below grade:
Material of constructs w. concrete—metal—fiberglass_polyethylene
_otber(explain)
- If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no _(attach a copy,of
certificate) ,
Dimensions: X,
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: �� '
Scum thickness: it
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendation inlet and outlet to or baffle condition,"structural integrity,liquid levels
as related to putlet i vert, vidence of leakage,etc.
C
GREASE TRAP:_(locate site plan)
Depth below grade:
Material of construction: concrete_metal_fiberglass_polyethylene other
(explain):
Dimensions: .
Scum thickness: n '
Distance from top o scum to op of outlet tee or baffle:
Distance from bo m of scum to bottom of outlet tee or baffle:
Date of last pu ing:
Comments on umping recommendations,inlet and outlet tee or bathe condition,structural integrity,liquid levels
as related to tlet invert,evidence of leakage,etc.):
4
Title 5 Inspection Fonim 6/15/N00
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: � 0 q
AA A
d I't
Owner: I k 1,41
Date of Inspection:
TIGHT or HOLDING TANK: (tank m t be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: Vinworking
s
Design Flow: ns/day
Alarm present(yes or no
Alarm level: A order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or o t of box,etc.):
� G
IF go,
PUMP CHAMBER: /or ):
ite plan)
Pumps in working order(yAlarms in working order(Comments(note conditionmber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of I 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
Owner 6/'
Date of Ins ection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
aching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
_innovative/alternative system.Type/name of technology:..
Comments(note condition of soil,signs of hydraulic failure,level ofpondin ,damp soil,condition of vegetation,
etc.): �.
In Is'
CESSPOOLS: (cess ool must be pumped as part of inspection)(locate'on site plan)
Number and configurati n: f `
Depth—top of liquid t inlet invert_:
Depth of solids layer:
Depth of scum layer
Dimensions of ces ool:
Materials of cons ction:
Indication of gr ndwater inflow(yes or no):
Comments(no condition.of soil,signs.of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (loca on site plan)
Materials of con ction:
Dimensions:
Depth of solids: -
Comments(no condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,,etc.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: d c L
A Ai
t- 1,4+
Owner: "
Date of Ins ection:
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.El
P
F
� y
t IN:J�—
Title 5 Inspection Form 6/15/2000
Page 11 of 11
OFFICIAL INSPECTION FORM—..NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ,"" / E
3
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet fit
Please indicate(check)all methods used to determine the high ground water elevation:
arced from system design plans on record-if checked,date of design Plan reviewed:
,ObtObserved site(abutting property/obs"ervation hole within 150 feet of SAS_
Checked with local Board of Health-explain:
�ecked with.local excavators,installers-(attach documentation) .
cessed USGS database-explain:
You must d cribe how you established the high ground water elevation:
i C,
�q - Y
l C;✓
Title 5 Inspection Form 6/15/2000 11
COMMONWEALTH OIL' MASSACHLTSETTS
EXECUTIVE'OFFICE OF ENVIRONMENTAL AFFAi S J U N 5 Z001
DEPARTMENT OF ENVIRONMENTAL PROTEC I89ALTH DEPT.
RECEIVED
i
K JUN 2 1 .2 001
1ITLE 5 TOWN ARNSTABLE
OFFICIAL INSPECTION.FORM -NOT FOR VOLUNTARY ASSE S1VII NAZH DEPT.
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION.,;.
Property Address: _ _ Y
Owner's Name: 4 2
Owner's Addrerilpb_Q-� Al)A RECEIVED
Date of Inspection:
Name of Inspector: (please tint) �1 17 '�' ':. JUN 1 12001
Company Name
" t TOWN OF BARNSTABLE
Mailing Address:' - - 7 r/ HEALTH DEPT.
Telephone Number; =Z 7L- IIJ�
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time ofI 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
eeds urther Evaluation by the Local Approving Authority
Inspector's.Signature: i Date: a�
The system inspector shall submit a copy of this insp�ction report to the Approving Authority(Board of Health or
Y i
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system_owner and copies sent to the buyer,if applicable, and the approving
authority:
Notes and Comments'
""This report only describes conditions at the time of inspection and under the conditions of use at-that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/1.5/2000 page 1
i
Paget-of 1.1 ti
OFFICIAL INSPECTION FORM—NOT,FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�► , t !'`_ _ '.. PART A
CERTIFICATION (continued) .
A
Owner:: ,
Date of pection:
Inspection.Summary: Check.A,B,C,D or E/ALWAYS,complete all of Section D
A: ystem Passes:
I have.not found any information whirh indicates th t any of the fa ' re critel'la U Jcr:Vcd In 31vMiZ
15:303 or in 310 CMR 15.304 exist.Any failure criteria notlevaluated are indicated below.
Comments:
B. System Conditionally Passes:.
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the fort 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 taiik 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 wate(level in the distribution box due to broken or
obstructed pipe(s)or due to abroken,settled or uneven distribution box. System-will pass inspection if.(with.
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution.box is leveed or replaced
ND explain:
The system required pumping more.than A 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:
2
Page 3 of I'1
OFFICIAL INSPECTION FORM NIOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of�ySgection /S"lU/
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 r
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 t1he public health,safety and environment:
The system has a septic tank and soil abso.ption 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 l of a public water supply.
The system has a septic tank and SAS andthe SAS is within 501feet of a private watersupply well.
_ The system has a septic tank and SAS and the SAS is less than 100:feet but 50 feet or more from a
private water supply well**. Method used to;determine distance
**This system passes if the W'el W' aier analysis,perfbr—nai.d at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates.that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.,provided that no other
failure criteria are triggered.A•copy of the analysis must be attached to this form.
3. Other:
3
i
Page 4 of 11
I . -
j
OFFICIAL-INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A'
CERTIFICATION(continued)
Property Address: �,ce
Owner:
Date of pection: J
D. . System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following f r all inspections:
yes N
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 l
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 i Ivert.or available volume is.less than %day flow
`r Required pumping more than 4 times in the last 1year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is bellow 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 One 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,forlcoliform bacteria and volatile organic.compounds
indicates that the well is.free from pollution from that facility and the:presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A.copy of the analysis must be�attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,.therefore the system fails. The system owner should contact the Board of .
Health to determine what will be necessary to correct the failure.
E. Large e Systems:
To be considered a large.*systemthe system must serve a facility with a'design flow of 10.,000 gpd to.15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinkmg�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. Theo er or operator of any large system considered a
significant threat under Section E or failed under Section D Ihall upgrade the system in accordance with 310 CMR
15.304.The system owner.should contact the appropriate reiional office of the Department.
4
Page 5 of 1.1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM
PART B
CHECKLIST
Property Address:
Owner: IMA
Date of spection: /Q .
Check if the following have been done. You must indicate"Yes"or"no"as,to each of the following;
Yes
Pumping.information.was provided by the owner,occupant,or.Board of Health.
_ Were.any of the system components pumped out in the previous two.weeks? ,
lz�_ Has the system received normal flows in the
previous two week period?
JZ 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? l
— Was the site inspected for signs of breakout?
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:
. y
Yes /no
a/ Existing information. For example,a plan.at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11 —
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACI' SE WAG,E'DISPOSAL_SYSTEM INSPECTION FORM
PART C
=1 SYSTEM INiFA ORMAT ION
Property Address: r
Owner:
Date o spection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(design): . Number of.bedrooms(actual):._.
DESIGN flow based'on 310 CvIR 15.203 (for example: 11:0 gpd x#of bedrooms):3��
Number of current'residents: _�_ el rt
Does residence:have.a garbage grinder(yes or no);�(r
Is laundry on a separate sewage system(yes or no f if yes separate inspection required)
Laundry system inspected(yes or no &-
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no) j
Last date of occupancy;62�_
COMMERCIAL/INDUSTRIAL /90—
Type of establishment:
Design flow.(based on 310 CMR 15.203), ... igpd. .
Basis of design..flow(§eats/persons/sgft,ete.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes-or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no)`. . .,,.
Water meter readings, if available:
Last date of occupancy/use:
j
OTHER(describe): j
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection.(ye.s or no):
7 If yes,volume pumped: gallons--How was iivantitypumpeci determined? " - .Y' "`'_
Reason Tor pumping: A
TYKE OF SYSTEM
_/Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
Shared system.(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology.Attach a 'copy
.of the current operation and maintenance.,contract(to be
obtained from system owner)
_Tight tank _Attach a copy'of.the'D) P.approval , • ;, , a`• -
_Other(describe): .
Approximate age of all,components,date installed(if known)and source of information:
.:
Wer!Lwage odors-detected when arriving.at the site(yes�or noL ¢
6
I "
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
owner
• 4
Date o �tpection:
BUILDING SEWER(locate on site plan)`
Depth below grade: ,
Materiais of construction: cast iron 40 isVC . ot1hCr(exp ain):
Distance from private water supply well or suction line;:
Comments(on condition of joints, venting,evidence o�leakage,etc.):
SEPTIC TANK: /(locate on site plan)
Depth below grade:
Material of constructionncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age: 1s age confirmed.by a Cehificate of Compliance(yes or no):_(attach,a copy of
certificate)
Dimensions: 10•6
Sludge depth:
Distance from top of sludge to bottom of outlet tee or Baffle: 3 .
Scum thickness: �i
Distance from top of scum to top of outlet tee or bafflel:
Distance from bottom of scum to bottom of outlet tee or baffle:�—
How were dimensions determined:( 1 �td�l -
Comments(on pumping recommen ations,inlet and outlet tee or baffle condition,structural..integrity, liquid levels
s related to outlet invert evidence of leakage,a .).
b 01 �),S
GREASE TRA�locate on.site'plan)
Depth below grade:
Material of construction: concrete_metal_fib,erglass - Polyethylene_other
(explain): —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
_Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural;integrity, liquid levels .
as related to outlet invert,evidence of leakage,etc.):
7 .
I
Page 8 of 11
OFFICIAL INSPECTION FORM—.NOT FOR V.OLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE`DISPOSAiL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
A .
� .
Property Address: Vl ,
/4
Owner:
Date of spection:
TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal , _fiberglass polyethylene_.._other(explain):
Dimensions: i
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):L
Date of last pumping: I
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: t/(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: � J
Comments(note if box is level and distribut�tooputlets equal,any evidence of solids carryover, any evidence of
1 kage into or out of box,etc.):
PUMP CHAMBE (locate on site plan)
Pumps in working order(yes or no):.
Alarms in working orde.r.(yes or no):Comments(note.condition of pump chamber,condition of pumps and appurtenances,etc.):
I
I
i
8
. 1
Page 9 of]1
,:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date o spection:
SOIL ABSORPTION SYSTEM (SAS):Zoocate.on site plan,excavation not required)'
•If SAS not located explain why:
Type
leaching.pits,number:_
hing chambers,number:
leaching galleries,number: ,
leaching trenches,number, length: -
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil; condition of vegetation,
G�
CESSPOOL'S° (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: . j p
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication.of groundwater`.nflow(yes o,:n 1):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVYc.-J-
4�Aloc.ate on site plan) `
Materials of construction: v
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10.of 11
OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
PART C
SYSTEM INFORMATION;(continued)
Property Address: A
A
Owner:
Date o pection:
i
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.
I 4
a
a� c yq
0
o
I
10
Page 11 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFO ATION(continued)
Property Address:
Own P-42
Datepection:
SITE EXAM
Slope
Surface water
Check cellar I
,Shallow wells,
Estimated depth to ground water 175 feet j
Please indicate(check)all methods used to determine:tl a high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
_Checked with local excavators, installers-(attach(documentation)
-/Accessed USG.S database-explain:
You must describe how you established the high groin d water elevation:
l
I
i
11 .
fi
�g TOWN OF OF BARNSTABLE O.
LOCATION SEWAGE# 3-3
VILLAGE 64m dn�a �•�^D ASSESSOR'S MAP &LOT 419'4,6I
INSTALLER'S NAME&PHONE NO. lvrt It77� 1Vu 1tv
SEPTIC TANK CAPACITY
�� ��
LEACHING FACILITY: (type) o �rteas (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: COMPL°ANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
-Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of•leachng facility) Feet
Furnished by 4
�� tots
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for XDiow5al *pmem Construction permit
Application is hereby made for a Permit to Construct(X)or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. N tkP `AAS YPGi- tc j Owner's Name,Address and Tel.No.
40.&I&A QJt Q
Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No.
t'•�s r
s09-3&2 8132-
Type of Building:
Dwelling No.of Bedrooms ao Garbage Grinder(Pv)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow er gallons per day. Calculated daily flow �>2>® gallons.
Plan Date 't Z, Number of sheets 1 Revision Date
Title _<4-PTI c S YSTM-4 2o t>csL9 I,--
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board f e h.
Signed Date
Application Approved by- ,c.L 1 23
Application Disapproved for the following reasons
Permit No. T9 ?3 3 Date Issued
R
[- .y,.,•�^'�..^+...mrf n.�;-tyi.1•-«.R t. . .. -.,s -��t..':7+: '-`r:�»,..r.i�c'x"` -a. .'F3�'"„�., ' -._, .. w - '�' lti.>t -1.`_...�.i".'.�...^"-.�+. •.� �'- `S•'�M.nr�i
a t 1 jj 7, 114
f4
No. P W r '� Fee
v ' THE COMMONWEALTH.OF MASSACHUSETTTS;,
PUBLIC HEALTHyDIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS `-
'
pplicatton for Migpo!aY`*pgtem Construction Permit
tit �''
Application is hereby made for a Permit to ConstrucQX)or Repair( )an On-site Sewage Drsposal System at:
Location Addresss or Lot No. H*9 --W S L. t9 Owner's Name,Address and Tel.No.
4oM&AAca04p P\
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. a
s09- 3G2-8131-
Type of Building: "^
Dwelling No:of Bedrooms ' Garbage Grinder(&Ao)
Other ` Type of Building - .rNo. of Persons - Showers( ) Cafeteria( )
70ther Fixtures
' Design Flow 3�C� gallons per day. Calculated daily flow 33 O gallons.
Plan Date 9G Number of sheets 1 Revision Date
Title _yd P c S YST�+�-� D�-s��� "• 2i� l..Y�uC h#. Tz . `^
Description of Soil aP> T
Nature of Repairs'or Alterations(Answer when applicable)
`i
Date last inspected:
Agreement: w -
The undersigned agrees to ensure the construction and main enance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmentaf Code and not to place the system in operation until aCertifi-
cate of Compliance has been issued by this Boa�fe1
Signed �i - Date
Application Approved by ' cam �, 2r�
" Application Disapproved for the following reasons
Permit No. I(.P �?3 Da iIssued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance - a s
¢ THIS IS TO CERTIFY,that t e On-site Sewage Disposal System installed(�or re�faired/re-placed(, )on yby
/11lar Sla ti 4ti♦ J by a /�Q �X, for
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. datedF --- ''
Use of this system is conditioned on'c�rnpliance with the provisioN set forth below:
t i �
No. �`-T ✓ " Fee 00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
Miopoml 6pelem Construction Permit
Permission is hereb granted to i �/f�_
to construct( repair( )an On-site Sewage System located at 140 dr
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.
All construction must be completed within two years of the date below.
Date: Approved by
,
,
,
ACCESS COV S UST B WITHIN ,
A SS ER M E THI
INVERT N ERT EL V T l S S E � � DE 1 GN CR / -TER 1 A
>. � � 9 ,MlN1MUM. .
6 0 , F GRADE
F FINISH
99. 653♦ MAXIMUM COVER INVERT AT BUILDING
DESIGN FLOW:2. TO ,
V
f N ER T I N P T I C TANK 9 35 : .��...BEDROOMS A T_11Q.. G P D R
BE tEv£c' ' E PER
,
0 MIN 2 OF _.;
BEDROOM
INVERT OUT SEPTIC ''TANK, 9�/O
EDR M EQUALS : G. P D.
> 4 PVC'. ,
3/4 - / / 2/ DIA.
SCHEDULE E 40 e INVERT 99 ,
H L N R T IN Q l s r Box . 0
o :WASHED STONE , .
6 .. . 6t4s
GARBAGE'GR I NDER _ ;
o e e e o a INVERT `OU D S 0 98
— 1 T. BOX:
99.3 aaFFce 9s.o
i INVERT
I N LEACH 98, 6
OUTLET 3 4 X 6 FL OWD l FFUSORS .
o ,, .- ., SEPTIC_TANK ;REQUIRED: ._
W/'3 STONE' SIDES. 4 ENDS. I UDR, .:
- ► ► ,, D-BOX UNDER SOTTO 6
1500 M OF LEACH CHAMBER 9 . 6 : ,
GAL 330 660
q ► G. P.D♦ X 200x GAL .
SEPTIC TANK ADJUSTED GROUND WA NIA
► � � � 6 CRUSHED STONE BASE D ER
SEPTIC TANK PROVIDED: 1500 GAL'. A,
T
� OBSERVED GROUND` WATER; � N/AIF
► ►
i
i
► ► t \
BOTTOM TOM OF TEST HOLE �2. 9 I: 6
PROFILE NOT To SCALE ..SOIL .ABSORPTION SYSTEM REQUIRED.
i ► i
DESIGN PERC RATE. . � 6 MIN/INCH
SOIL TEXTURAL CLASS
► 0 70
EFFLUENT LOADING RATE GPDJSF
�. Apo . �Q GPD '/ .7 GPD/SF - 47_1 S.F.
lZ
s, . . PROVIDED: 3- 6 �FLOwD FFU ORS W/3
_ OSE P .. . r
1
0
.. R ED
a
♦
.v .. _ STONESIDES, 4 os U
P
R ..
1
d
----------
SOIL TEST PIT DA TA
.: ter, "--._.. � � �. s ;, .. �� �^-_
_ � ,, r
♦ - ab. ,
�- i _ _.. � . ... .. _.. INDICATES ..INDICATES
PERCOLATION OBSERVED -
.. A► . _
TEST - GROUNDWATER
,y . . �� ��
HYD rAv ♦lQO'' ri . �„ �. ..� '� . -.. ""��.. ��`:� k ..�"'� �-� TP* r i
_-- -�656 S.f _�
w --
'`'� GRND EL. 107.3 G 101.6
'
'� -,. � � RND EL
fo . ♦ K.
-TQ L dRE�- NIA NIA
•
HOR 1 ZON, TEXTURE COLOR OTHER
�. __ HORIZON TEXTURE COLOR OTHER
�'� ��.' �l, �� . 107,3 0 10116
11�
�. an ti
LOAMY 0
LOAMY IOYR
SAND 5/8
--
-~ --- LOAMY TOY W
R WELL GRADED lOYR STONES AND
SAND 5/B
_ SAND COMPACT 714 COBBLES
!� „
t
t '?*
105.0
4 .. � __ .. WELL GRADED 0 STONES '. � - � � _ r YRAND
GENERAL NO TES :
R µ 3 � x e ��. MD/FFUsdRs � SAND COMPACT'.. 7/4 COBBLES
e t
W/3 STPNf'J)Df.4 f 3
ti
t. l UNDER
I THIS PLAN 5 FOR' THE DESIGN D C UCT10 . o°�' e L I F E AN ONSTR N � ,� � R � � =--------
F THE SEWAGE DISPOSAL SYSTEM ONLY.
r , ___
2. ALL CONSTRUCTION METHODS AND MATERIALS AND .
IN E'NANCE OF .THE SEPTICSYSTEM SHALL
r
� � J N WA 0 IY N WA
ti s TP 4. 2 9/,6
CONFORM TO MASS � � � Soo sA -..
D.E.P.D.E.P.' TITLE 3 ANA.LO AL s � � � L `� 0 •
a SEPTIC rAHK'
BOARD OFHEALTH _ cU s RE REGULATIONS.
MAY 30. 1996
� . k DATE.
e
• » •'
J. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER � STEPNEN 'HAAS .. ..
N TEST 8Y
AREAS SUBJECT TO VEHICULAR TRAFFIC OR GR AT � 4
F £ ER
� tP� aH�s FHD WITNESSED BY. ED B RY ,.
=THAN J JNDEPTH SHALL 'BE CAPABLE OF �'!TH
. ( 6 :
PERORATE. Ml I C
STANDING H 20 WHEEL LOADS. � ,
4. ALL SEW R - P S ,.
E Pl E HALL BE SCHEDULE 40 OR � ,.
APPROVED EQUAL.
1
5 BEFORE C0 a
,a
B F RE CONSTRUCTION CALL 'DIG-SAFE'.
.
O L T 7 M.4 S S
t 800-322-4e44 � � R T4N L A /VE' ,
AND THE LOCAL WA DEPT.- ,
uTE
FOR LOCATION OF UNDERGROUND UT S ,
R �✓;J T� S L..' E . < UMM,•4 G1(J I LJ
O
6• VERTICAL DATUM IS: ASSUMED
f R P
T. . :FOR BENCH MARKS
E r4 RELY FOR ,
M R SET. SEE SITE PLAN. ,
G'I�NAfAGU D.
! O
8 0
GOLF CLUB
b -
,
N DETERMINATION 5`l N HAS BEEN MADE AS TO
co�rP I A c -wr L N E WITH DEED RESTRICTIONS OR 70NlNC
REGULATIONS.
g, . -., Yti
T SHALL' REMA l N THE CLIENTS .,a ., /�(� //A�� /♦\/( ♦♦♦ /y^�/ ..k.. .,l ...;.. I� + , Fr?..� • ♦ I\ �./ ! ♦ I ! �I^1 �! � I S..i �� \J .:
RESPONSIBILITY �^ J T0OB A a _OBTAIN ALL PERMI TS. `SPECIAL _ .,
t, w ,
..p.. ,.:.., 3#�d... a,...
u N- » a. ... : ..� ♦ �. fie .
PERMITS. ETC: FORT l S PROJECT. � � �H E ,.n:. �. ., , , , , SCALE . _ I 3 O
.,,..
.. ., 4...w. '"�:A a -.....
LOCUS , . R.
+r
: m« ....
9. ANY RETAINING W W _TAININ ALL SHOWN oh THIS PLAN IS OR w ,� �
.. . . . ,
♦,T C
Oc oONLY :. .. ..L A T l N AND SHALL IN
h . _ r
�> Y ,
ACCORDANCE WITH STANDARD PRACTICE. x . M. .
,
Q r
Ro f •.
T . ,
fXt T
...
,tom m �= ` ` ;
, 1 a z �.l IT SHALL REMAIN THE CL7 T S RESPO S B TY 7 Z /£N N l 1L! f I}L
TO VPROPOSED
HA T --
E HE U
B l L D 1 NG FOUNDATION � 3 2.
DESIGNED l
l NED 0 ,
T ACCOUNT OR THE EXISTING GRADE
•.`� � 3 ♦-
1 _
AN 1L COND1 TIONS AT THE LOCATION 0 L T1 N F THE
P00 _, ,, ,.
RP5£DBU BUILDING.
'` l5 _ . 30
,nr� I 'c 60 _ . . ...
U C l./a1 n
Q/
PoB. 0: ,96 ,N 267 FIELD CFWIEEK_ CA L C. S /C W . ; - .
AH F CffECK CFK DRN. SAH . . ;