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HomeMy WebLinkAbout0009 WINGFOOT DRIVE - Health y 91WINGFOOT DRIVE, BARNSTABLE 349 076 d 9 j a v A if n m � u COM OV EALTH OF TVLASSACIrUTSETTS ExEcuTivE OFFICE OF ENvioNTNIEN-rAL AFFAIRS VT DEPARTMENT OF ENVIRONM ENTAL III.®TECTIOI! s RECEIVE® AP PARCEL NOV 3 2004 LOT 19 TOWN OF BARNSTABLE TITLE 5 HEALTH CREPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARS'A v CERTIFICATION Property Address: qWir' Owner's Name: pry 637 Owner's Address: �0 Date of Inspection: ty q A5( Name of Inspector: please print) Company Name: r c yh, tb`%�, Mailing Address: Telephone Number•. it �gS ZOO CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a PEP approved system inspector pursuant to Section 15-4Q of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: _/0�� `-"� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address ltow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Forth 6/15/20W page I i 1 f Page 2 of 1 I OFFICIAL INSPECTION FORD-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 10 t Inspection Summary: Check A;,C�D or E/ALWAYS complete all of Section D A. System Passes: A— 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"sectio eed to be replaced or repaired.The system,upon completion of the replacement or repair,as approved the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follo ' g statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exEltration tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic approved by the Board of Health. *A metal septic tank will pass inspection if it is cttually sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years of available. ND explain: Observation of sewage bac or break out or High static water level in the distribution box due to broken or obstructed pipe(s)or due to a b en,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)aye zcpkced obstruction i svemoved distribution n box is knied or replaced ND explain: The required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass' on if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 0. r c� Owner: Date of Inspection: Q C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Heal 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 Seca ance with 310 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect blic health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface wa r Cesspool or privy is within 50 feet of a borderin vegetated wetland or a salt marsh 2. System will fail unless the Board of H Ith(and Public Water Supplier,if any)determines that the system is functioning in a manner that tests 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 supply or trib o a surface water supply. _ The system has a septi and SAS and the SAS is within a Zone I of a public water supply. The system has a s tic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup p well".Method used to determine distance "This system asses if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and latile organic compounds indicates that the well is free from pollution from that facility and the presenc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure ria are triggered.A copy of the analysis must be attached to this form. 3. ther: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DMOSALSYSTEM INSPECTION FORM PART.A- CERTIFICATION(continued) Property Address: �_i�G-U Owner: Date of Inspection: O 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'i/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped . — Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. T Any portion of a cesspool or privy is less than l 00 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 cWffwm bacteria and volatile organic.compe�ds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than fi ppm,provided that no other-failure criteria are triggered.A copy of the analysis must be attar to this form.] (Yes/No)The system fails.I have determined that one or more ofthe above failure criteria exist as described in 310 CNIR 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 facili with a design flow of 10,000 gpd to 15,000 gpd• r You must indicate either"yes"or`to"to each of the folla g (The following criteria apply to large systems in ad ' " to the criteria above) yes no the system is within 400 feet of urface drinking water supply the system is within 200 f of a tributary to a surface drinking water supply the system is locate a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a pub' water supply well If you have answered' es"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D ve the large system has failed.Theo Q� y caner or operator of any tame system considered a significant threat er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHEdCKLIST . Property Address: i�l �M u Owner. #!C KAI �_ Date of Inspection: Check if the following have been done You must indicate"yes"or"no"as to each of the following: s 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? K_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition 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 inie­nance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,aplan 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)j310 CN% 15.302(3)(b)] r 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: W% Owner: Mew( Date of Inspection:_ In 1 WaO __. FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: ff_ Does residence have a garbage grinder(yes or no):Ab Is laundry on a separate sewage system(yes or no): Ab f if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): W Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no)A)00 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): -apd Basis of design flow(seats/persons/soft- Grease traXe): es or no): Industrial ng tank pr nt(yes or no):, Non-sanitschar to the Title 5 system(yes or no):_ Water me if ilable: Last date use: OTHER GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):SAD If yes,volume pumped: .gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 9 Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of al components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):�JO 6 Page 7 of I i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: All CND{o Date of Inspection: O I Taco BUILDING SEWER(locate on site plan) . Depth below grade. Materials of construction:_cast iron X40 PVC_other(explain): Distance from private water supply well or suction Iine: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: K (locate on site plan) Depth below grade: (3" Material of construction: concrete metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) / Dimensions: /pdy gc✓! Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 90" Scum thickness: f it It Distance from top of scum to top of outlet tee or baffle:�_ , Distance from bottom of scum to bottom of outlet tee gr baffle: IS' How were dimensions determined: . JI`z�i�( Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related o outlet invert,evidence of leakage,etc.}: 'E Uj t its k 7, % GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal rglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of o et tee or baffle: Distance from bottom of scum to om of outlet tee or baffle: Date of last pumping: Comments(on pumping reco endations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,ev" ence of leakage,etc.): 7 f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i dotutv Owner: Ali ewt Date of Inspection:_ lam( 0 TIGHT or HOLDING TANK: (tank must be pum time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete Infiberglass_polyethylene other(explain): Dimensions: Capacity: ons Design Flow: allons/day Alarm present(yes or no): Alarm level: Al in working order(yes or no): Date of last pumping: Comments(conditio of alarm and float switches,etc.): DISTRIBUTION BOX: K (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (Iocate;site }Pumps in working order(yes or noAlarms in working order(yes or noComments(note condition of pumpondition of pumps and appurtenances,etc.): 8 Page 9 of 11 1 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _� W i Owner:_A ,Qfift— Date of Inspection: to SOIL ABSORPTION SYSTEM(SAS): (locate on site plats,excavation not required) If SAS not located explain why Type leaching pits,numben a leaching chambers,number leaching galleries,number: leaching trenches,number,length: Ieaching 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.): CESSPOOLS:. (cesspool must be pumped as 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 in ow(yes or no): Comments(note conditio f 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 oil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q W 1 1► [�� ywt .��— Owner. N&Is Date of Inspection: .- �( 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 eaters the building_ a� q5 a7 3 � Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOI..UtNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q `.,w Owner: j Date of Inspection: p SITE EXAM Slope NO. Surface water U� Check cellar V16. Shallow wells Na Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) 9 Accessed USGS database-explain: You must describe how you established the high ground water$�w elevation: o as Sj , 11 173 MAP 4 J l LOT PAR COMMONWEALTH OF MASSAC HUSE�;ITS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS b DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:C1 1k)IKY• rm-r OR Owner's Name:-jj}C--0 y?C 'P)WQ-NT Owner's Address: A win-) r--GOT nfZ• RECEIVED Date of Inspection: 1.1 7 DEC 0 ZOO' Name of Inspector: Dion C. Dugan Company Name: 1543 Main St. TOWN OF BARNSTABLE Mailing Address: Brewster, MA 02631 HEALTH DEPT. Telephone Number: (508)896-9390 ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails - Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments * Recommend: N alntdnanee pumping every 3 5 yrs. -11"This report only describes conditions at the time of inspcction 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 ]nspectiun Dunn 6/15/2000 page t 11;ige 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: q j jjl!tiG1`f QT DR ��►UST Y�Lt= . Owner: ' ' Date of Inspection:_J. t p Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. System Passes: t/ 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: System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or no etermined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal d over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiil 'on or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a comp. ' septic tank as approved by the Board of Health. *A metal septic tank will pass inspection i it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o is available. ND explain: Observation of sewage backup or break out or high tic water level in the distribution box due to broken or obstructed pipe(s)ordue to a broken,settled or uneven distrib 'on 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 , T ND explain: fhe system required pumping more than 4 times a year due to broken or obstructe ipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed NO explain: Page I of OFFICIAL INSPECTION FORM - NOT FUR VOLUNTARY ASSESSMENTS SU13SUIZFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT A CF,RTIFICA'TION (continued) Property Address: l�)I lUC1=E)UT �'Z Owner: 1+450no lU"T Date of Inspection: f 1 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No -zBackup 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 t/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool �✓ rquid depth in cesspool is less than 6"below invert or available volume is less than%day flow eqtured 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 I of a public well. ��AnyAny portion of a cesspool or privy is within 50 feet of a private water supply well.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.]Q_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gp`d 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) N/A the system is within 400 feet of a surface drinking water supply N/A _ the system is within 200 Icel of a tributary to a surface drinking water supply N/A — :he system is located in a nitrogen sensitive area(interim Wellhead Protection Area IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section G 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 I or Bailed under Section D shall upgrade the system in accordance with 310 CMR 5.304. The system owner should contact the appropriate regional oflicc of the Department. , I;age 5 of 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUI3SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT I3 CHECKLIST Property Address: I�JIy�YKl7)T �(Z• (�i 1?t' & a} L1r' Owner - L - Date of Inspection: Check if the following have been done. You must indicate`2es"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? _LZ _ 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) _L/_ Was the facility or dwelling inspected for signs of sewage backup _ Was the site inspected for signs of break out? V _ Were all system components,excluding the SAS,located on site? i _✓_ 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? 1 The size and location of the Soil Absorption System(SAS)on the site has-been determined based on: ! r Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J p 1'age G of t OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: lUlflaC�lT i171�� Owner:UEnLx)01r Date of Inspection: O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):,,. Number of current residents: Does residence have a garbage grinder(yes or no): � Is laundry on a separate sewage system(yes or no):t&)[if yes separate inspection required] Laundry system inspected(yes or no):jy Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): 1999 3 56 000 gals. 2000 3'�$,000 gals. Sump pump(yes or no): Last date of occupancy: COo?,Q9itl t C O M M ER C IA L/IND U S TRIAL Type of establishment: Design flow(based on 310 CMR 15.203 : gpd. Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: ' OTHER(describe): , GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): d If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: JTE 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner), Tight tuck Attach a copy of the DEP approval ---Other(describe): Approximate age of all components,Pte kyalled(if known)and source of ill f rmation: Were sewage odors defected when arriving at the site(yes or no): No I • a OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 1'roperty Address: 0ji )6RYJT 1p2- Owncr: Date of Inspection: f G BUILDING SEWER(locate on site plan) tl Depth below grade: 22 Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): :rolh1Tnfft121C -T16L�; yEymNG jGX 2nor )n SIGk)c or Lr�KjgG SEPTIC TANK: locate on site plan) Depth below grade: ID" Material of construction:V/—concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: [f u N Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: < Distance from top of scum to top of outlet tee or baffle: fit'_ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: by tape and rod Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 1Iy l!�On !cl�roc tu,eo0j L Ca 01 f7 nz . 444"C-46 * Recommend: Maintenance pumping every 3 - 5 yrs.- GREASE TRAP: locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: , Distance from top of scum to top of outlet tee or baffle: ' Distance from bottom of scum to bottom of outlet tee or fiaftle: _ Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invcrt,'eVidence of leakage, etc.): OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 Ckmt 1`00T U2 t�►4 vt�Sfir4Y�.�_— _ Owner Date of Inspection: I � TIGHT or HOLDING TANK: /V (tank must be pumped at time of inspection)(loczte on site plan) Depth below grade: 3 Material of construction: concrete metal fiberglass Polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) u Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): —you iS 1,, g,ijCL L f-R,1&13 C2h nx I S AAQ7- —'CC�/_ CRE60e",a / A S a -, 66 i N sfALLA lb) PUMP CHAMBER: /r (locate on site plan) Y Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 1111.. C'..I , 1 /00110 t Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: O[ ujipl 6(' MT ,N Owner Date of Inspection: t SOIL ABSORPTION SYSTEM(SAS): L (locate on site plan,excavation not required) If SAS not located explain why: Ty leaching pits,number:_ /O fa r,e p/-r5 kvb/ 10NA—C leaching chambers,number: leaching galleries,number: ` leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �� IW 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 or no): Comments(note"condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): " Recommend: Maintenance pumping every 3 5 yrs. PRIVY: N/A (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.): q r 1'abe 10 of OFFICIAL INSPECTION FORM.— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: Q L�I>\�C�FmT 3�YZ - r3.�}12rvST-Vi 1�LE . Owner: Date of Inspection: 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 build g. . A - t ►-- # � y 0 I4- ^ r !4 - E r i.:cj 10 11age I I of OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued):. Property Address:Q (u(K)G FCOT uz y Owner::16Lf)Ybrj1'� P Date of Inspection:—1 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Ibserved site(abutting property/observation hole within 150 feet of SAS) hecked with local Board of Health-explain: hecked with local excavators,installers-(attach documentation) . Accessed USGS database-explain: P/_^T-E 2- You must describe how you established the high ground water elevation: �. usr, S xtL .4 p, r tt GRAM= ,- <5E9 CO/VPOAg11-10A) p,46-6 41 C eb Permit Number: Date: /I f O/ � Completed by: DION C DUGAN — HIGH GROUNDWATER LEVEL COMPUTATION Site Locallon: ---_1 iyllyGr_Cor )DA AARIV5111#4L Lot No. Owner: �Q��'- j�/4RElUr" Address:_ .SArtic Cuntractor:-_2>-�—(f, D&C-4 AJ Address: / 4,3 , 1,41A) Notes: STEP I Mitasure depth to water table D tonearest 1/10 It. ....................:...................................................... f ate mon hldav/year STEP 2 Usiny Water.Level Range Zone and Index Well Map locate site and determine: fW Iq Appropriate index well...............:..........:....................:.... 13, Water-level range zone ..................................................... G STEP 3 Using monthly report "Current r Water Resources Conditions" i determine current depth to watei level for index well ........................... mOnthlYear , I STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth l to water level for index well (STEP 3), ,ind waiter lcvcl zone (STEP 28) determine water-level adjustment .............................. n a STEP 5 Estimate depth to high water by subtracting the water- , level adjustment (STEP 4) from measured depth to water Irvel .it site (STEP I) ...................... .. . .................... ......_..... ............... - Figure 13.--Reproducible computation form. _ {, • 15 - 1 �.y Y "­_-i,,�-,�-11.-,,UIF-'-rk t i. + + t 1 v j g..f n i s ti ., s .- `' K i,..r - '?i .r-rP O-- s �.,u ` .. k ^-r'S i So- 'kte7 ���}r d t i <...I�� -trig v 1 "� i a '.a ? r �� ^" ti"'" l.� ,� „•,k 1.t`r ry T't`i ai r 4, s, -:. ���- -. 0, c 1 Tax '�'"`` T f `s .�a. .n may. £ fir. y"'�'?''.'' *mac--z. _ R,;Z; Utz ..r �- .s" -;o � -. T-�i' .:,k ,'� r ' r "r, ...2"'�." x' _ 1, __ _ i4:_-. T+ J' r.,-'e 'f,, i f L 4 3 °+ A k - J ey 1� ��� �` f -� �or�'u�lO tY�fe�]tt t�ofi�1IIO oC#1>;JSBttS; jl� , s v 4 - iceC B r -t -1- lronrr�ent 7h-I fs ' a - - ,� D E F True Freptrc Inspector r D'+�pa�ftsfe�t a z P'0 Bex 2119`" �> � sv pa mental Profo I , Ta 6 ket,IvF, Q2536r k �? ...,�,. - .. i ! -�+^ MCERTiFIc F M.,,.�.. .}_. :a S t4 - - ice+ 4E 6ISPOSAL;SYSTEM INSPECTION FORMeyk_PART A x- r., c^ e' ti�.� ATION r r, , . S �� `^r _ v E ;, r P A *y C - d ,. { Propeity,Address ; WtngF- Rd Cum : _ I h a Address of Owner ` t' Date of.lnspeI . 9rzsree < _ (If dlffarent) -'t �� Name of Inspector John Graci ;Venud Box 254 r r4� .:. r fi- 5 7i r "� ` 1 - Company Name,Address and Telephone Number ,' ` a .k ' t 5' x, 2 ' a -'ii s r 's 9 Z ; ti y :, ":r s CERTIFICATION STATEMENT' , -: ` 'l certify that I have personally inspected the sewage disposal system at this address and that the information reported beio"is true accurate � +j i '`and"co'mptete as of the'.time ofaf specUon' The mspection'was performed based-on-mytraining and experience n he proper.function and maintenance of-on-site sewage disposa(systems; The system. -_ frs < r 9 X Passes t ,, ' Conditionally Passes "` , '' a '' f _`Needs Furthar Evaluation By the Local Approving Authority Fails I I{ r � r r q a f Inspector's Signature:' /"� I5 bate:,er26196�J :ti ... .. a_. The.System Inspector.shall submit a copy of this inspection report to the Approving_Authority within thirty..(30):days.of completing this, inspections..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-regionaloffice of-the Department of Emieonrriental Protection'. ' `' The original shouid`be.sent to-the system owner and copies sentto the buyer. if applicable a_ d the approwing authority 'f I . - k e - ..-'i i & t T �� ' I' INSPECTION SUMMARY ` Check A B ,.or D Y Aj:SYSTEM PA$SE3: , . :.;; . .,..., :; „ '- x t have not found any i' orrr-ation which indicates that the"'system violates any of the failure criteria defined as in.310 CMR-15.303: Any failure criteria not evaluated are indicated'below . Bj SYSTEM CONDITIONALLY PASSES: K\ _One or more system components need to be replaced or-repaired„-The system,.upon:completion ofithe replacement or repair,passes inspection . . -. . Indlcate.yes no''.or not determinetl(Y N.or ND) >,Describe basis of deierrtlmationin ail instances :,If noi.detetmined" explain why not) The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltrabon;or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved ` F by the,Board of Health: s.- _ ;. (revised 11115195) _ .. k• , ,. f.� ... 3 r:..;' ; ,S One Winter Street,s;.8oston..Massachusetts 02108 :• FAX(6,1'7)551i-1049 • dTelepho ie(61T);292-5500 xW„ ; nr * a , r 4 0. 'i t n- 't ,: t `t' 4 r c $i' �.0 ya* - ) � 4 s o a,� r J- � - a4 f��.4k � 4 r * .s ti t I { . � '� ."� .a`r�.,:; a ,s -� e r ?z Y L F sUBSU;RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMsr y *` I' ' -PART A . k y �,_ x s CERTIFICATION (continued) _ '? umml uId s PropertyAddress: 9 Mnn Foot Rd C q Y x } Vent:box 254 x Owner. ,�< ""Dati�-oYhlSpecCreFt-9F_ . _ _ 4. _ T 4 t 9 Se a e acizap ortrreakout or,h�gi�staUcwater level observed m the distnbubon box is,due to a`.broken t I g settled or ureven,distribution box Th1.e.system will pass inspection if(wr#h approval of the 8�ard 03 Health) 1. k 44 broken"pipe(s)are replaced � E ' obstruction is.removed.. } distribution box s leveled or replaced w :r ,, "- The - } ' _Theaystem.--'u ed'pumping more than four.times a year due to broken". obstructed pipes) jY "system will pats inspection if,(with approval of the Board of Health) , broken pipes)are replaced ; t y `' { - obstruction is removed. T , ,: 3 „ C] FURTHER;EVALUATION IS REQUIRED BY THE BOARD OF HEALTH s �- k 4 3 - _ _ =Conditions exist which regwre further evaluation by the Board of Health m order to.Qeterm', ,C the { « _ _ system is failing to protect the pubUc health safety and the environment 1) SYSTEM WILL"`PASS.UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM'IS -,`NOT FUNCTIONING IN:A MANNER WHICH WILL PROTECT,THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT -1 j > b,^ Y r 1. Cesspool or privy is within SO feet of a`surface water, .. vegetated tat ed w4.etland or a salt marsh e Cesspool or privy is within 50 feet of a bordering g y) SYSTEM WILL FAIL UNLESS THE BORN A MANNER THAT PROTECT HTE PURL C HEALTH AND SAFETYEAND THEMINES THAT THE SYSTEM IS FUNCTIONING ENVIRONMENT: - .; t _ The system has a septic tank and soil absorption system and is within 100 feet to a ^ ; . surface of water suppiy.ortribufary to a surface water supply ,. p ;, Ttie system has a septic tank.and sal absorption system and is within a Zone 1 of a pubfc water . supply well...: s. The system has a septic tank and soil absorptiomsystem and 1 .within 50,feet 6.of.'a private water t 1. supply well: 1.19 _ The system has a Septic,ta1.nk and soil:absos Sttfor:eol forrn on-system abacterea volatile-at le o ganec cornoounds indicates that the well is water supply.well, unless a well water analy is free.from pollution.for that facility and.the presence of.ammonia:rntrogen and nitrate nitrogen is.equal or less than 5 ppm 3) OTHER ,. . . .- . . . . r D]'. SYSTEM FAILS: I have determined that the system violates one or more of th'e following failure criteria as`defined`n 3t0 CMR t5:303: The basisfor this determination is,identified belowi The Board of Health should. contacfed to determine what wilt be necessary to,correct the failure ed SA S Sear or.clo " e in facili or system component due to an overloaded 99 . of sewa . S - B acku 9 .. K .. P6.,.' cesspool `_. , Discharge or,ponding of effluent to the surface of the ground or surface waters due to an overloaded"or clogged " cesspool ,.r , - . r ; . < SAS is in hydraulic failure. ,,i, Fn. S r - 4 ,- R (revised,11f1S,9 s �; r. . ,- 1 ..�,.. 4 F . . . - c' { n •x . .. 4 y N :. •w -w.r vw2•s a-s. .k,�,. Y •e", x-'.g +. •CS, i7.'t ,M t d"G .L Y e ?,�k `k-i-� i' °'• s A,'d ? s � d �� �' ✓C 7wc a �",s Yi-t "" �a."' ��' � fYfe11 tTcLir 1 . �— '� ati a F`s_1, -" ,r ..s r .�• :t - <� ..ter_ x. 1 _ u, - z' .,,:g a�'�-r.�• .:4xm .s �._ :,i..,_ ,.a. '"�'_ �" s 'A,�; x T f �`tt""xit - k f Y- > F..� I 4,r3 " ,� s € t,, F r iP i s r # '4 t 1 _ e q z s s s.i, t r` xt a F'{ , ,_ , "� ^ SUBSURFACE:SEWAGE QtSPOSAL S`75TEM lilSPECZION FORM , a r , 1 t - P r CER.TiFICi4TOf�(contlnued) ;1', a` ' � , f. ¢<`' x �; I Is r I Y3 t t i t', ~a Rn x y s}1 I._ y k tom. t + _ { -. « f - PiopertyAddress: 91MngFaotRd Cummiquid rk %" a c - ''+ F r•-3 ':Dade aInspacLOir� 9(26/96_ - r .� _.:. yr s } k xc-._ ,� d,1 W i, 1 s - ,7-w>- s L Dj SYSTEM FAILS(continued) a x " + vi A° G Q k.Static liquid level m the distribution box above outlet invertdu6 to an overloaded or clogged, SAS or cesspool , r ? !I Liquid'depth m cesspoofis less flan 6 below invert or available volume is ess than 1/2 day flow ._x i. " -_' s s. .. . x_ Se t k.. Required pumping more than 4 Umes in the last year NOT due to,-clogged or obstructed pipes) I. r c z f F Numbers of times pumped '. '- ? F Y r- u r { i Any port(on'oit the Soil Absorption System cesspool or privy is below the high groundwater w elevation ': 3: Y Any"portion of a cesspool or privy is within 100 feet of'a surface water supply or tributary to a surface water supply . � ; Any portion of a.:cesspool or envy is within a Zone 1 of a public well . I '. i. ,x, Y .t j L : t, , Any,portion of a cesspool or privy is Nith.in o0 feet of a private water supply well z t — - _ .A ort. of ,I,- -spool or privy is less than 100 feet but greater than 5a feet from a private water supply>weil with no - , ny p. acceptable waterquality analysis If the well has-been analyzed.to be.acceptable;`attach copy of well water anaiysas for coliform bacteria,volatile organic compounds, ammonia.nitrogen and nitrate nitrogen ., , F Ej LARGE SYSTEM FAILS ` The following criteria apply to large systems m addition'to:the criteria . The system-serves a facility with a design flow,of 10,000 gpd or'greater(Large System)arid the system is a signrficant threat to public health and safety and the environment because one•or more of the .following conditions exist: �. ., 1 `"' :�..r the system is;withm 40a'feet of`a surface drinking 4vater supply ;F n the system is.within 200 feet of a tributary to a surface dunking water supply . - - .. _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public water:supply_well): - - . - . 4 , The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program F-I requirements of 314 CUR 5.00 and 6.00: 'Please consult the local regional office of the Depart...t r further information ,, ,,, , - . . . �- _ . . . , ":. y, v t a G C I x;, - y i { i_ ti�. Y k'% !�' , { F x Y 2I - y. k� £ x .., - t (revised 11115I9, - Y r: a 3`; '' :` Yzl I F, '' ,•s2,k' .'F ."•, cfi.`? h•' `d �i` S^`i •�- 7 - 4s=±. . , t 'a r� r �? �_- � p x � - ...cam U I - 4 7 4 4 ,, — Jr' L S,H,� ail et h) �-`E # ?�, 9 4 1 S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -k ., y' i; - � PART B:'' < +,; k ', ; :Ek Y L' r - r CFECLIST ' Y r� t 'w y c i `r a 5 ,k # r ty X q y �, t: Property Address 9 WingFootRd.Cummlquid rt 1 a, ' *` _� 4. -Owner f'._ Venutl:BOX254-• F n ;x k y ,fi q; x: r-,�, s * 1 i. '4 -�•�rY "e } .7-. :} f ..--• W a ..... i.. :M. '- ,*' i i ° r ,t : a ay �. '+ to Check if'the following have been done f XPumping information'was requested of-the ewn6r occupant and Board of Health + 3- r s`been receiving normal x. w` k nd.the and the" stem ha g x 'None of the'system components have.:been.pumped for at least two ee s a Y. . . r' flow rates during that,period. Large volumes of.water have not.been introduced into the system fecently or as part of this'• �' t;. 't N F ri 'k _Y : �nspebtion ° ' ' 5 i d t o '� ` t I aAs built plans have been obtained and`examined Note if they are not available'with NIA 4 �,- $ a , z : 4 l: t' :1 s :',rE, } i 4 • x The facilitybr dwelling was inspected for signs of sewage back up � 7' K sr 1 .1 5+... 'x v n n-sanitar or.industnal waste..flow T.he system:does not recei,e o y 4 , z s F�� n r,:. x The site was inspected for signs of breakout 3 _ s o r X a r s x All system eomponerts excluding the.Soil Absorption ySystem,have been located on the site �t , `,_ $ a,; X 'The septic tank manholes were uncovered,,opened and the interior of the septic tank Was inspected « i,7 for condition of baffles.or tees,matenal.of construction;dimensions;depth of,liquid depth of-sludge, depth.of scum x The size and locaiion of the Soil Absorption System on the site has been determined_based on`ewsting:information or approximated by non-intrusive methods ,, . a— . x The facility owner(and,occupants if,different;from owner)were provided with information on the proper maintenance of Sub Surface Disposal System �- ' 1 i { y7' .. ., r ti ;r .:. .. y Y ;Y ry 7 f t }' . . . y . I ' ., x. ii _ ..' z , sr. �, aP S ay @ )' « c v a f An'. ,'� r A k a - a { i, 3 u m ", _ . ... .. :. a'r' .. :: .f t t } r - S - - s _ - } , �, is F (revised-1t115195) ,y2 r` r7 + r z, 3 4 ' Y,, :x 5 i ,, -� r. + s ..' ,. . . . ,:, + � { ty A 4 � x r. �-ss t �r T dot a. k # i 'y{ l 4 9f �.. t *•-f s x rf r t si e 4 3+: .fit 3 F p{ .: ( t , a k x t `' #* y1=,+ ;K SUBSUR`FAtE SEWAGE DISROSAL,SYSTENTlNSPECTION FORM P `v xf '� .- -'fact-r`•*' '^ k^•r�� '; yc --...a "' •...0 L. +,. -.a::.�§-.� w .,. •.-� �c * „{` ^sr-�"':--i'w �*3*.--s, tee. .L.x tr`- ✓• o- s=.. "s > r a7 � ^c- - hA r r SY TEN4INfARMy4 F©Al� � ��s._ .� -� d �*' - tti v 5 ry' e T .t :^>ti T r � 7',� •'-� _ s `` l sT.. 'a t ;t y.�,,., r.. s _ 'S— ,ems C, .µ...,t t .1. '` f - '.5 -; Y t,Vt t� fi iK t, r �z > ' - c;PropertyAddress 91MngFoo�Rd.Cummlquid < , , .$ � t 1, ur y Cr01 fl`e'I" .� ti L121.. n 9Sd f r.r.r 1 r ; •., y *a 3t9�G A-SPAGt�+O.n-. .Q6 ...,.,._+--;.•_ t .,k..., •y ..J. *� s. a J ., k ;,c -,jam..-�+ .Y f E *r a : . , f v FLOW CONDITIONS td ,. 4 A 4 RESIDENTIAL s z > i ;r ` ¢ s F `4 °Design flow 550` gallons ,,. t _ f r �', Numberof bedrooms 5' r s x , 4, € yz r r Number:of current residents 3 ` ;t k Garbaoe grinder(yes or no) Yes: 4 - Laundry connecfed to system(yes or no)4 Yes X ,� .. Iy Seasonal use:(yes or no}; No _-- rY w ` Water meter readings`if:available, Na ` w ' `: 5 - '-- .. _ .... .r. . I'' f V5 E 'Y�, _j .�Y F 'Ss ar y2 Y d Last date of occupancy'n!a :; k i4f , i 4 y 7 G :. 4 ..4 ) COMMERCIAL/INDUSTRIAL 'i jJ , ' Type of estabUshment: nla 1 ' 'r a R $` � i� %. t ` Design flow a gallons/day - `' r Grease trap present (yes or no) No , } r ' k ', ' Industrial Waste"Holding Tank present (yes o,no) No z k " Non-sanita waste discharged tothe Title S s. stem. es� i rY 9 Y (Y or no) No - ' E ` `Watermeterreadings f:available: nla .. - _ .. ..::: ..,. ::_ i.'r , t-.` `. 'Last date of occupancy .rya t 3 I. OTHER: (Describe) n1a r ; z 't, . Last date of,occupancy:=_ - `' � s . .... t GENERAL INFORMATION .: F .: c s " ti PUMPING RECORDS and source of information'„ � 4 '� system was last pumped one year-ago by Maccamber•.. '' System pumped as,part of inspection (yes or no)No h 4 If yes,volume pumped::6• gallons ,T Reasonfor pumping: n/a •f `z TYPE OF SYSTEM - ; - X ' Septic tank/distribution`box/soil absorptions system Single cesspool } Overflow cesspool. { Privy Shared system(yes or no) (.if yes;attach previous inspect ionrecords,if any) Other(explain) . . , h F 6 ;r. APPROXIMATE AGE of'all components,date installed(if known)and source information z 1986 Sewage odors detected'when arriving at the site: (yes.or no) Noi ; - . r �%r ' (revised 11115/95) / r s c. ~ R.t . 4 r 4r A 5 �_, : 4 •�'` 9 . ....: -,e 3 T� r tr t f k� jr.r 3.'f "' Y'J' 5 `` t a r.A n . fi_c,�1L 3y �J. t i:a:.'�.. ` fie?.-"7'"s -• "',�?.J'�r'6�F-z� .t.'� •s ^, .,aim 'T en '. ,*r.L-✓ t'l.N e'�" 6,}'�1x ' a°1 -U-•' ° �s"�# ..,..Ro�':: y d �`4 5..,'y�+' s`�6�+,tr':Lr° -ra .}t.'.�.w� n u.�x.-,. -�era..,:.�i w 4, •s. i :( a i -: 'Tf } .5 a t- �, u M ., .' ; Y'k c t .: ,uy.c i a k �,v� tJ h+ _-k ,�` yY i t r y fi s L rx.. �, x yr- a .f ,. ' k • -e , 5:; e x ';� f C.: '.ask r ; .' , 1 ?" ..ram. _K 4, I ,,r:, - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` '� ? S � PART C - "'" + 5�(STEM�tNFORMATIC7 (CoxltlTttlsd} ,,, L s Y -' — i t t s , ' �r x J ,'' t� Y r 1 1 z: x t 'h. f > _ •t ° ?. Y� k y, .+-� a { .4 h- rv..r - ..M x '.S' - ' .1 , k "' )Property,Addfess x,9WIngFaotRd:Cummiquld r ti r s a, r, r - r A , Owner :+ yenutl Box 254 .. , '` ` �,; f ¢ + y_ �''�' v_ a e o 'nspec o � t Y b ,I 4r SEPTIC*TANK _ s '-' ' (locate on site plan) ' f -.i C ` -Y.: • if4 Y F % 1 % .may'-. _ . i SF RI -� .u!' i - i 4+ _ A Depth below grade { j z Material of constructior%'x concreate metal FRP other(explan) : ;.- .... 1, r Dimensions Lt0'6 H 5'7'':W 5 8' { ,. r " Sfud a depth:3' � E 5- r F `- r s K 5 Distance.from top of sludge to bottom of outlet tee or baffle 24 4­ �r _ F { .. s y f , f h 1 ;5c6 4 thickness:9 _ '-Distance from top of scum to top of outlet tee or baffle 5 ' _ f Distance form bottom of scum to bottom of outlet tee or baffle r f v} f r ,^ _ 'Y''>+- `f Zh t f t�# S�` F "� s '�� Z n 4 s ,r* x". ," 1 o- s t a 1. i J ( z 2 } t '�S s v �_ S Comments _ (recommendation for pumpmg condition oT inlet:and outlet tees or baffles ;depth of-hquid eyel m relation to outlet invert struc#oral integrity �, `, evidence of leakage,etci.) 'J L, Septic tank and alfcomponents are structurally sound.Recommend pumping`system every two years for maintenance r t 'r ry GREASE TRAP: (locate on site plan) ` . - --. - 4 J& J... 'yI. i_Y tr 'Depth below grade Na Material of construction: _concrete_metal_FRP_other(explain) Dimensions:.nfa Scum thickness:n!a , ° 4 ; Distance from top of scum to'top of.outlef tee or baffle:nra a 4 Distance from bottom of scum to bottom'of outtet'tee or:baffle: n!a _ r Comments , >. �' (recommendation for pumping, condition of inlet and outlet tees'or baffles, depth of liquid level in relation to,outlet m4ert structural integrity evidence of leakage,etc.) =' Na t r i % - ,:'"II � - �,1­ 't :I.I- � -Zr-_�19�-_�� 1;�� � �1 �: ,. t� �'tII,.. , _ ,�- �, z,i ,} - :. - -- t _ 4 . / 7 �j h "F; l - «' - i t v J y �.� -'` `, i , s t Y':� , ` .j ,•.i Y e '�}S L t (reused 1'1/15f93) r z ' .. - , , ., , t' v. T t ".�- -� `' -'a`'t r`F 'a s`. 'd.. 'r —�r`J:.,:. r k t Y s ��p } • k F I­--''"+�' ,t, t 't-e� Y'!, r "` s. ",,-ta tic b is fz asf'c b,..*`$'sy a. ,3 r"K„w ^i-,.r 4_ bS a $ 4 N N y !}sy ly ..} } . k 3:. F y- y ,r:y t , ,2,'& �.� k i lr.r 'bi^ , x" t v' 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM M PART CT:, e t F -- y t. `# ;.SYSTEM INFORMATION(continued) x 1 ,- -..--. y 9,1 f +..-., } ,... ._ Z. -cam J "� r� k A' tr.. ° + s 7 .'` s { Property'AddresS 9WIngFootRd Cummiquid r . T7 `:F:, n r I'1 f nf:1,n5 pgC1'0,(La9/2�96 L c w ;` -:. - ... s G i s CIGtiT OR HOLDING TANK z 4` (locate on site plan) z 3,g c r r p� Depth below grade Na _ i `3 ,P,`;Matenal:`of construction concrete metal FRP othec(exp,,,"'. ' T � F r I. � :: -. - , - } f; z ° ! "f s ,}x r •n r'i'a° t6 Era a 3K �5 t 4. 4 ,' ,,, li Dimensions Na' £ 2 r . -,z Y w a Capacity n!a gallons a ;L .. / x t f :.Desig.ri flow n!b gallons/day sf ; F ,. 7 'a 3 r Alarm level nla .. ;3 7 .4 1 E a , 5 t R w r { 3TM f } r i a 5 �, K q F -+; ) �,.i j { t ,4a t t.. Y. Comments ` <: 4." k- t ,(condition of inlet tee condition of alarm and float switches etc ) s fi r ,. �_ 4 x . -` t *t z - , ;.Na. x a ,;t :. '!tr a x f L .t'l•. . y AY - Y ^ 'S ' S t r y i 's J e r I1 DISTRIBUTION BOX X-. (locate on site plan) 1 Depth of liquid level above outlet invert.;Llquidieveiwithbottomotpipe ` 7 Comments. 1 N 3 ; . (note if level and distribution is equal evidence of solids carryover evidence of l9 1 tia, into or out of box etc) - D box is structural sound. h „. .. . C $ kip 3 £' - .. :.: L - :...-. sl . t Y PUMP CHAMBER: :f (locate on site plan) ' : "'.Pumps in working order(yes.orho) z':r - - .. . :; , - .. Comments: -, ,, (note condition of pump chamber condi-tion of pumps and appurtenances;etc ) nla ,�. 4. . - <: - i, r - ..,h _ .. ,r. t ... :, f {. x t !: t -. .. . . . - f - / (revised Iv15f95). .. .. 1. l 4.. .. - - .-_. . - - ., .. .: 11 - *..z-,n:a a x _ .�+ ,.,- `-",� f�'sx _., + �.. -r'; it 2 wn �a,. _ t �+ ;.,. �#a ns �v M r tam 00 G t� x Y F ,. .y •} s "r•X'$ S 5a.-is'.`i � "C."c'• .C'#"`-s."-, --t' n..3.-'e �.,�'�s=Y:-,"'«,=+�'w;',- s :^-•x,�, - ,._ r k«A�r-:.-�....�. asnc - `.-a -r•-,.,,:s«�.«. 1. 'FAT F*� ..1`s �d-�b-a1 �'�_ '�.. "�.-.tv,.�C' "'.S iL Y' J -._.h4t.�" 3 .'l t - y `..-" "�S r�5g rw ..1 �y C +>y��.y�.� � F.: -...., ._. rf - PM1 •,?'A' F4/ ^C ` f <R tW .. d �. �,x4,1-."' "..'�„'a+ ."e _�.!"tli ac?'Y. _. ,max-' .. p -,x� t f3. -,+-z #'�"ryzm.*• !. Y 1 R -?v tt t.r ':: C ac'�' sue• v�+- e:r.,�,.'t1. �.r •ayx +;re w '? -e' _ -7i + f "'. }, 'w r� '� $ " . .-',.a 'x #�•s 'r•„ 3e.s '..x°" .� t 'xi 7. sy ;Y e r`t "" 'nCS,"LL ,xs -9 '" "1.,s. .,5 _ -c-,. T-. 's ..t Fl f A , �a.-r £+,-.x .�._ ,a =x-.r'�_s a.. '.�,�"" 'r ..,,-+ .ri-,. «.. - +, s f .r y-�" `c,�K s '�' .ac�.�' . 'csr` "-.," W - T f, SUBSIJRFA ,SEV GE Di 3"A S �EMcINSFE6T1ON'FORM " �x4 `� Y t s l ri`'�"Tr •,�..+ sF'¢, _n-y..,� - ,,, . r.. .�,.-4k ��s- '�� -+s'-"'�';M1yix .'._'sue• I—i .t I -h•4..^- u+—•--•�. rr—. "a t *'M' .�-.sa > i3 T y r .,�.�-.�.<,+' -. -s,'Y sa'"'i _ t m: SYST -fFlF4Fi)fA?TU+N(cbt�tlnuad� F;.� ,. -k .-._....,�. r�-Ts.'.�„ �t-ri `k- .'s._ - _ _ice.. 7^ 3'r-.� _ r�a" .> €-.—�. A>.. _rn -.+ s ..1 .e } .a,. - _3°' �,Ej .y<a.'.s t f .a ,y 'r Pro a rf ;Address 9 UYIngFoot Rd Cummiquld - r 1 k i Owner e .T _ - ,, •a e o �nsi3e'c-ro _ �a f SOIL ABSORPTION SYSTEM (SAS) X a 4 ^ `.(locate on site-ptan +f poss+ble excavation not required but may be approximated by non-intrus+ve methods) „If riot determined to be present explain ' M; a VVI. k ' 1, z : a Na , TYPe � 4 I; hin Its number 1,000gallonleachQlta L a `Y v y 9P r ! - -.leaching chambers number nta '! - f r _ ; >- :1 r - , ' } v Y � >!: w 4 c j t z 1. leaching galle[i,es, number 'y' <1 n!a Na �:.r ,u a z" 7 f § t k x fi Y t leaching trendies,number length k, x leaching fields.;number, dimensions nfa. s " a3" »' ' ` n!a r ­ overflow cesspool number t t - a1 ; [ ` 4 ;xte k 'k ,< .'.> -. , -tt '� .�Z t � . F' r 'Comments (note condition of soil;signs of hydraulic failure level of pontlIng condition of vegetation etc.) c M. k r_ :4" t The leach pft is structurally`saund and functioning properly c - Z J j", 3' y , 3 4 Y Y „ ;{ CESSPOOLS: r _ y x (locate on site plan) r .. r s k r , 4�Number and configuration n!a �' ;Depth-top of liquid to inlet invert: Na Depth,of solids layer: n!a Na r Depth of scum layer: ` ' ' Dimensions of cesspool:' Na , c 4 - Materials of construction: - Na j' ,• ' -, rt` Indication of groundwater: nla` '' ' inflow.(cesspool must-be pumped�as part of inspection) �'z " ` _ Na . : 1 .. ;. Comments:-.(note condition of.soi1, signs of hydraulic failure level of ponding condition of vegetation etc) � " Na f T': 'x � ' 'I c t:; k: PRIVY: (locate on site plan) , { Materials of construction: nla ' Dimensions nla Depth;of solids Na ' Comments:(note condition of.soii.s+gns`of hydraulic failure, level of ponding'condition of vegetation etc ) - .. P�ivyComments > , T . f 1. , ( 2 - F '? ., S 11 % I i .t. 5�. r. tr ,. t , + ti y r. '{ - 4' I 4' R t t C a ;t .3 - - - _ S tip' �- ^+ (tensed t1115f95) � »i ,,< {_:. 4 f_. .. r • r yyci' 1 i ..•. ��-''; -�' .-I-l .,1 - ��'----- , ." - .l . , , , $:- -I - 1 -.;.. - �1.. 1 - d �� fi . � K � tL � , ,x , .. - - li P �ftQA41- - -- � � . - � -+� - -. . e o� ,O 1�A' - , -.-4,r� " <�-*4M - % 1M i -- " � _4j k Z "e ( ,,N V �-,F i , -s , 1 � �Oi F t ., �, a SUBSURFACE ISEWAGE'DISPOSAL , ?A- ­ A' 1--;I " P_.. .. V SYSTEN!iNPOZMATI ON"(6 uii.9d , , �1- " " � � , � - -t -,S�Z ,, �, � -t t � -� T -- r a -r - tV �'-t. �, t --�"14-,, - �L- �J�-M1 f ; .- I-I i .I�.- � - - I "I I . ..". . I I I . I � I , I- - V, I ���I- . -, - .. �, ,7-.. �"".., - -7;-2�'.-! 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I .,��I I . ,, . � : - I � I � ��� I �..i, ., -.�-�I I. .� . ,�,�I , .- tf I . ,,-,,�, , I ..1� , -:,, ., , . -.� ,, ;, I" - -, -I -�,- �. :�. ,.�, ,.... ,,. ..- -.,�l I"' 1, i rI -.;--� j . k . , " ' y ; � , - -%.� -I -I ' , { 4 . �7i �� Y, ;t' ' 'T � , �j , , k ". .- � �. , .- ,-i- ; I 4 .- - , a- , p - e-�,,t.1I 3 , ..;I,c fit,. � A I7...; A-, , I I -� ." -� Y n 7�1��..�l I� I- 1I, •- :�., i 4 ,-, �.: ,., .1... -..". i:, DEPTWT GROUNDWATER ,i -Z.,,� .�I......4 - ,Ir A Depth to groundwater- 12 feet V, t method of determination-or approxmatio, f �USGS Maps and Charts . . -- ,.1.. I, ;1 I (revised 11115195)- " { . � 1l. � , -- - -- - . I �--------- - - ---- LOCATION ,, SEWAGE PERMIT NO. VILLAGE i -,INSTA LLER3 NAME i ,ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1,4z& i M L--T ti O O o � o 3© o P4A2 S7fowS rr Fiz$ ..y............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........_:...OF................a. ZS' ............-.. ,t Appliration for Uiupuual Marko Tomitrurtivaa amit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: �p -•...Loca ion-Add es ...............115.h"_.�°� ?c 1;-- 1------__o-------------- •.............-•Lt.J ........1.7�a r.Lot /v.'..._........................-- Owner (y,,. Address y� / M InstallW Address Q7i Type of Building Size Lot............................ feet U Dwelling No. of Bedrooms. ..................................Expansion Attic ( ) Garbage Grin ; r aOther—Type of Building ...... .................. No. of persons............................ Showers ( ) — Cafeter Other fixtures -------------------------------------------------•--•. W Design Flow............................................gallons per person per day. Total daily flow............................................gal Ions. 04 Septic Tank—Liquid capacity/.Z5Q.gallons Length_/`-.-0_'P Width.... ..�V. Diameter________________ Depth_._' W Disposal.Trench—No..................... Width.................... Total Length.....................Total leaching area.__.._..•..•...•...•sq. ft. Seepage Pit No...... ----------- Diameter.._.�oo.sa��_ Depth below inlet.... ,........... Total leaching area.,Y4�c -€t.4G P D, Z Other Distribution box (>ej Dosing tank ( ) Percolation,Test Results Performed by.Lo!�.. ...__ _ �- I��.._l�N. _�. Date.....7_2:7.-ngz........ ,� , • •a�n•� st Pit No. 1......4......mmutes per inch Depth of Test Pit---/80....... Depth to ground water.,9 T' st Pit No. 2—.............minutes per inch Depth of Test Pit.................... Depth to ground wate ........... Description of Soil..................j6A:�-L.......----- -------------------------------•----------------....-•--- V ,,... ------- - --------•---- /'/ .... i L ----- ---- W - ------------ ear, o `�-----------•-------•-----•---- U Nature'of Repairs rd Alterations—Answer when ap icable._.............................................................................................. •-----.---•=-•-•-•••-•---•--•••-----•-•----•.....-•---••-••-•-••••-•-•-----•--••-••••..............•-•--------••--•----------•----•-•-•-•-••-••---•---•--••--•---•-••-••-••--•••-....-•--•--•-..._-•--- Ag �r reement: �r - The undersigned agrees to install the a redescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanita y Code— The undersigned further agrees not to place the system in operation until a Certificate of Complianc has een issued by the board of health. igned. -- . --- --••• -- ... •--- Application Approved By...... --------- .............. .... .. ..........• ... ------- Date Application Disapproved f r t following reasons---------------••----------------------------------------------------------------•-------•------•-•---•---....... •......••-•----------•--....-----•----------•---•--...-•--------••--------------••-----•••••------........_...-•--•-----------------•------------------------------------••---------•---•---•-----....... Date PermitNo........................................................ Issued•••••••••-------._.._....-------•-.__.._._ Date r�.�'. - F�s.....L ......... • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... _m').L -..............OF................ ApplirFa#iou for Bispwi al Vorkg Tonstrnrtinn Frrmit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: ..ne -------------G.....=------ g ..................................... . Location-Address or Lot No. yam' f . ..7. _. ..r........_ .... ....................... ---.----- w •------------•------ � •--• T'1 C�........ ©�.O pd�ly�j��l� �� UType of Building Size Lot..........................! ._ feet Dwelling—No. of Bedrooms. ............ .........................Expansion Attic ( ) Garbage Grin er Other—Type of Building ............ No. of persons.......................... Showers a g ------ -------- P -- ( ) — Cafete ' dOther fixtures -----•--•------------------------•-•------------...------•-•••----•---------•-------•------••---••-•---•---......_..-----••-•-....-----••......•••--- w Design Flow..............................--------------gallons per person per day. Total daily flow..................•................:__......gallons. WSeptic Tank—Liquid capacity%2 ©..gallons Length/a'-D.'' Width----.5'no."Diameter---------------- Depth.. '__(,, x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.................... ft. Seepage Pit No.___.Z........... Diameter...f..©� �.. Depth below inlet.... Total leaching area .`e� tr. P , Z . Other Distribution box (-K) Dosing tank ( ) `-' Percolation Test Results Performed by.4-ate... 4411aLt4= R....AJ.1<__._. Date....1-. 7..:n6,3-------- Test Pit No. I...._.(I......minutes per inch Depth of Test Pit.../80........ Depth to ground .-- (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-O_gfJ:?"�` ---------- P4 .................................--..... O Description of Soil.................. 5.= .......�'�__. --•-•-------------•-----------------------------------........................................................ w UNature of Repairs or Alterations—Answer when applicable............................................................................................... .................--------------------------------------------------------------------------••....... ................................................................................................. Agreement: The undersigned agrees to install the. aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL 5 of the State Sa 'tary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance s been issued by the board of health. '' Sig --•-•_cas. ._ ... ' .............•• ................................ l Date Application Approved BY ...... f'= ..--•--------- -•...--••---••••-••--------------------•----•-••-•....... L------,G�; ate Application Disapproved f of the following reasons-----------------------•-----•-------------------------------------------------.----------••.•------•--------- .............................................................-............................................................................................................................................ Date PermitNo......................................................... Issued-....................................................... Date THEtCOMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... P Disposal Trr#if irtt#r of l f Tuntplianrr �H ��'�f rRzTIFY, That the Individual SewageS�stem constructed ` .!o'r�ReP aired T ) ( ) by - ----------:L ------ } ---i--------------------------------------------------------------------------•--•..•. 6 ��i✓" �.InstalC at..................................................................................... ............................................................---../�_ has been installed in accordance with the provisions of K3j,,F, o The State Sanitar ,gescribed in the application for Disposal Works Construction Permit No......................................... dater ____.......__.___................ T14E ISSUANCE OF.THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISFACTORY. DATE..----•-......•-•-••-f-- -1 loy..-----•---------••---•........ Inspector.. .K-'--•-----------------•-••---------------...-•---•------••-•-•--••--. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................OF..................................................................................... No......................... Fv.............. .... Dispontf nr nns#rnrtion Virrmit Permissionis hereby granted---•--- 1=' ----------------------------------------------------------------------------------------------------- to Construct ( e ir� ) an.Jrjdi S Tage Disposal'System j ---, f�= 'w' `, ------•--•------...- f {"' r _.Street as shown on the application for Disposal Works Construction Permit No..................... Dated......._...._......._......_............_. Ir ------------------------- ------- Board of Health DATE.................................................................................. FARM 1255. A. M. SULKIN. INC., BOSTON , ti �a • , , '*e to „ - .... -`x_",+..r• ems- __ _'++... --•._.,_.--..,--. . ._. .. _...... -.........._. , S 3 �``t•�� ; d '' r 2 !4 _ LAAE 1 f 5 O© `Y . I /cro T_E E X 7_E Aj D e X !5 f- .....e ._,..- o_.._.a...-.o __ f rQf''o5c d C?�rr-oo uu rr3l Ct!� fPar'-'oC"ft1 l/ee M/2 A A�O�,F'o LF�/NGla oH vE&ve S C7-0�oA-I 0 Qrz, S C�L 0 - V E- A2 7- � SCHED 4 O P. V C. Or2 EQU,9t- 7-0 SEP7-/C cmrnirrrur» f" per -Ycco+) Tfi N,� • ; a d � a a c T D/ST SOX ° tl 00 �a C�� �, _ _._. _____ (J.JGZ S�ed ,�I O r'l4� tl • � Q s C5, r � T E S T�, D /.v - - 1/ - _ / � t - !�> , f' M J h1 !A/C N "T 1 J 5 _ .: � r r-�= \ '`. ( i f L L+�✓ A , Tom. ALS. `L>r=)Y �i19TuM { A / 1 x , � a USE- :� /2 � T� TAB el �6 _ s s t � rO /DC— L'_.4 ±��5.�P �i'. r �f. t '"t� � - �/ �"9. 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