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HomeMy WebLinkAboutMiscellaneous - 80 BRIDGES LANE 4/30/2018F-411 NORTH 6 5 1 3 p4 •q40 1 Town of North Andover HEALTH DEPARTMENT ,,TS,CMU+t< CHECK #: d�g DATE: LOCATION: �� t, I a YELP H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ "**A Title 5 Inspector Title 5 Report $ $� ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Y Commonwealth of Massachusetts . ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form: Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood, Jr. cursor - do not Name of Inspector use the return key. none Company Name 24 Julie Ave Company Address Salem NH 03079 Citylrown State Zip Code 508-328-4633 870 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ ❑ Needs Further Evaluation by the Local Approving Authority JUN 0 3 2013 TOWN OF NORTH ANDOVER C 5/23/13 HEALTH DEPARTMENI Inspector ignature 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. ****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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owners Name North Andover MA 01845 5/23/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner's Name North Andover Cityrrown B. Certification (cont.) Yes No MA 01845 State Zip Code 5/23/13 Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner information is required for every page. Owner's Name North Andover City/Town D. System Information Description: Number of current residents: MA 01845 5/23/13 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No ❑ Yes ® No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped 4-16-11 Per BOH records gallons ® Commonwealth of Massachusetts ❑ v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped 4-16-11 Per BOH records gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Yes ® No ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. 0 Other (describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed in 1984 per as built on file at BOH Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 2'feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks qood in basement Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1.0 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 2" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. Citylrown D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Date of Inspection Scum thickness <1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? measure tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Sch 40 outlet tee in good condition. 1" of effluent in outlet tee due to pipe slope tipped back towards tank. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date feet ❑ polyethylene ❑ other (explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner's Name North Andover MA 01845 5/23/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box in good condition and equiped with flow levelers. No evidence of leakage in or out. Distribution equal. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Bridges Lane Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 5/23/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 Field 24'x 49' 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.): Area of system looks normal. No ponding, damp soil, or unusual vegetation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 80 Bridges Lane 5/23/13 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Property Address Bruce Favorat Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code 5/23/13 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -k t Owner information is required for every page. -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lan_ e — --- — Property Address Bruce Favorat owner's Name MA 01845— 5123/13 North Andover — State Zip Code Date of Inspection cityrrown D. System Information (cont.) Sketch Of Sewage Disposal nce landmarks or benchmarks. Locate alovide a view of the sewage l wells osal wi within 100 feet. including ostemlicates e at least two permanent reference where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately p�>TRN c�S A -TRa 1j, so Ma�SC -POP( s7, gP�13�X y?� �►� 27 O �(�CD I Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Bridges Lane Property Address Bruce Favorat Owner's Name North Andover MA 01845 5/23/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 6'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ►1 ■ ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS maps indicate soil is good with >6 foot water table. Basement of house is dry with no evidence of ever being wet. Wet area 50 feet from system is 10 feet below elevation of system Before filing this Inspection Report, please see Report Completeness Checklist on next page. Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Bridges Lane Property Address Bruce Favorat Owner information is required for every page. Owner's Name North Andover MA 01845 5/23/13 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Lot # Cp BOARD OF HEALTH DESIGN APPROVAL STREETSeptic Tank Permit # Proposed Construction 44"O&001-1 Approx Building Size Garage /under Attached None Min elevation of top of slab ZO Min elevation of top of foundation Height of foundation wall /7 Footing in fill yes ✓ no Further Comments COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 80 Bridges Lane _ North Andover_ Owner's Name: _Ronald Bennett _ Owner's Address: _80 Bridges Lane_ —North Andover, MA 01845_ Date of Inspection: 5/14/2004_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: > Date: _5/14/2004_ The system inspector shall submit a copy o this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _80 Bridges Lane_ _ North Andover— Owner: _Bennett_ Date of Inspection: _5/14/2004_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Bridges Lane _ North Andover— Owner: _Bennett Date of Inspection: _5/14/2004_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance _ _ "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Bridges Lane _ _ North Andover— Owner: _Bennett_ Date of Inspection: _5/14/2004 D. System Failure Criteria applicable to all systems: You must indicate `yes" or "no" to each of the following for all inspections: Yes No _ _No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool —No _ Liquid depth in cesspool is less than 6" below invert or available volume is V2 day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No Any portion of the SAS, cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 drinking water supply _ ^ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 80 Bridges Lane_ _ North Andover— Owner: _Bennett_ Date of Inspection: _5/14/2004_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? _Yes_ _ Has the system received normal flows in the previous two week period ? _No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) _Yes _ Was the facility or dwelling inspected for signs of sewage back up ? _Yes _ Was the site inspected for signs of break out ? _Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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 no _Yes_ _ Existing information. No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _80 Bridges Lane_ _ North Andover– Owner: _Bennett_ Date of Inspection: _5/14/2004_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of currant residents: _3 Does residence have a garbage grinder (yes or no): _No_ Is laundry on a separate sewage system (yes or no): _ No_ Laundry system inspected (yes or no): — Seasonal use: (yes or no): –No _ Water meter readings: Yes_ Sump pump (yes or no): _No_ Last date of occupancy: _Current COMMERCIALIMUSTRIAL 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: Pumped 2000, owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank Reason for pumping: _Inspect tank & tees_ TYPE OF SYSTEM _X 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 currant 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: _Tank & field installed 5/7/1984, as built plan, d -box replaced in 2000, info at B.O.H._ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _80 Bridges Lane _ North Andover Owner: _Bennett_ Date of Inspection: _5/14/2004_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: —24" _ Materials of construction: _X_ cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron thru wall to septic tank. 3" PVC in house SEPTIC TANK: X _ (locate on site plan) Depth below grade: _12"_ Material of construction: _X 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: 10' x 5' x 4' Sludge depth —4" _ _ Distance from top of sludge to bottom of outlet tee or baffle: 23"_ Scum thickness: _8" Distance from top of scum to top of outlet tee or baffle: _8"_ Distance from bottom of scum to bottom of outlet tee or baffle: _13"_. How were dimensions determined: _Difference between tee length & scum & sludge depths _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):_ Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of tank leaking out. _ GREASE TRAP: (locate on site plan) Depth below grade: _ Material of construction: _concrete _metal fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _80 Bridges Lane_ _ North Andover — Owner: _Bennett_ Date of Inspection: _5/14/2004_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0"_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):_ D -box level & distribution equal, has flow equalizers. No evidence of leakage out of d -box. Evidence of carryover, pumped d -box to clean_ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Bridges Lane_ _ North Andover— Owner: _Bennett_ Date of Inspection: _5/14/2004_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type — leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: X leaching fields, number, dimensions: _1 field 25' x 49'_ 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.): _ Soil ok. Vegetation ok. No sign of ponding to surface._ 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.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Bridges Lane _ _ North Andover— Owner: _Bennett_ Date of Inspection: _5/14/2004_ 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. A to 1= 4116" Ato2=50' A to D -Bog = 57' Bto1=31' Bto2=39'8" B to D -Bog = 47'4" 49' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _80 Bridges Lane_ _ North Andover — Owner: _Bennett Date of Inspection: _5/14/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water W_ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _3/23/1982_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: _ You must describe how you established the high ground water elevation: _ As per design plan_ ai- n s sF �� NS ,���yj!j' 'V.1 _" r ,• � +' .wSt r, �,@, n� � ., � ! 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'•�;•'�.. aI E � v s, .,s l7x tir� a-�cs,,�;"' 1 ' ''� a� +.'• y I ca4 •',' s a N.P ..•�?."'.•r4h's'' iil�'4r.� 11 �''� n •oul `sasudaalua uosalrg os#q • lta A. -uTalsAs oildas luomo moAjo uoilwado jogpT Rut, unnlosip Agaxag I put, `suoilnnjasgo Xw uodn pasuq ilazaw si gl!m3jog ponsst lzodw gonS -IuolsKs oildas 5upstxa agl jo Xlilmoilounj oql pue oBusn aminj jo aoluureng u alnlilsuoo lou scop utajaq paureluoo laodaa XW VOOZ/bT/S :uoi;aadsuI jo aleQ ljauuag :.iaumo .ianopuV q;joN lauu l sagppg OS :ssa.ippV 4aado.id poda-d uoilaadsul S anis 018I0 'sseW `zanopuV PEON nIIT.2jd I I I aoinzaSSiluidum(l 7y suialsXS ofldaS-ss3tn-1 iomaSS W-.iall-2u!juAuoxF[ • D- �L.1 ` 1J a IJ ra�al- l9- 1 ALO (mAJ al YjLl I9t,9-SLt, (8L6) :xL'3 98Lt,-9Lb (8L6) :101 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 7/14/00 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by Todd Bateson at 80 Bridges Lane D -Box & Outlet Tee Only has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector C.) W C c Z O Z i E a `o W J O_ (A LL W � F- Q W 'Q J W b = O LLO Z 0 U m V) ce. c o 4� W ro Z a� a H Z Ui � O `n M O c Q ce W w F- o O Q a`> 0 LL Z Q W c O Ov y Q p t ce Q o O z O ® o m 3 U O O J o 3 c O 0 O a cu L N Z QU 0 O a n �J C: M O D �•:'rF u U O bhp hMol *rtrt Q N G. cn LL APPLICATION FOR DISPOSAL WORDS CONSTRliCTION PE-RiMIT DATE: / ' xd aU CUi i RRET INSTALLER'S LICENSE LOCATION: /� . LICENSED I STI R: SIGNATURE: TELEPHONEr V15 CHECK ONE. REPAIR: L� NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOL-NDATION AS -BUILT. 575.00 Fee Attached? Foundation As-Buiit? Administrative Use Only Yes No Yes No Floor Plans?Yes No Approval Date: l D V� �y j-/,�67- i JUL 10--7 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at FO �Zk' )-/L,- relative to the application of 5c"✓ , dated 7 /a—Ou for plans by and dated revisions dated I understand and agree to the following obligations for management of this project: with 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed — generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to BOH, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation -or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. :ic Installer �� Date: m BRIDGES I I S ml /lY9 I LO 7 6 g;, 603 E I CERTIFY THAT , HL `_,f PTIC -_Y 1,T, EM V,A _ INSTALLEI AS SHOWN: -'HIS PLAN 15 NOT INT ENDE1)A,AINARRANTYOFTtiE VcSTE. , PLAN RMRANCF FROM PLAN b't PLA1ST01N C JfiSULTAU47S �NLAt,.:,HI)1VIN(-, 1B"J.1 CACF OHL_A 41-� GE _ DI'S C-) 5 A L ) t EI, { /�;-Edi I LY LCf;AT,I'� LOT6 LAI f- pA: E LISLE I = �O r'REPAREO BY --- FDYNI i Ic r_'1 1 135-00 <,I -- N58-41-,'29 w FLFVAT ION� HA,,-,�- _)L—LET 14Q,27 IhLJ T 13811 S T JU T t. E" if 7 9U U-60/ INLET 1,17E I U-bOX OUTLET IZ- 4y END FIELD 137.L4 ` - -- - r - — - I E I CERTIFY THAT , HL `_,f PTIC -_Y 1,T, EM V,A _ INSTALLEI AS SHOWN: -'HIS PLAN 15 NOT INT ENDE1)A,AINARRANTYOFTtiE VcSTE. , PLAN RMRANCF FROM PLAN b't PLA1ST01N C JfiSULTAU47S �NLAt,.:,HI)1VIN(-, 1B"J.1 CACF OHL_A 41-� GE _ DI'S C-) 5 A L ) t EI, { /�;-Edi I LY LCf;AT,I'� LOT6 LAI f- pA: E LISLE I = �O r'REPAREO BY --- FDYNI i Ic r_'1 1 tAV I CEpT{FY THAT THE SEPTIC {STEM WAS INSTALLED AS SHOWNe THIS PLAN IS NOT INTENDED AS A WARRANTY OF THE SYSTEAi, PLAN REFERANCE FROM PLAN BY PLAISTOW CONSULTAI'JS DATED 2-10-84 PLAr� SHOWIfNL SUBSURFACE cSEWERAGE_.__ - --� DISPOSAL SY'S TEKi AS -BU IL i LOCAT ICJN LOT6 BRIDGES LANE ;OWt\dER LYNCO REALTY Y T IUST WI E 5-7-84 SCALE 1= 40 PREPARED BY— j t FLYNN fiLTS50C P C' r r P 0, 5(-)/ J 6 9 PLA /s -)J(-' , 9-FVATIONS SOP FtvD 14EZ.8 I HOUSE 0L TLET 14027 i I ST INLF_T 138.1 S T OUTLET 17780 D-SGX INLET I'7;EI D -60X OUTLET ENG FIELD 137.c'-4 I CEpT{FY THAT THE SEPTIC {STEM WAS INSTALLED AS SHOWNe THIS PLAN IS NOT INTENDED AS A WARRANTY OF THE SYSTEAi, PLAN REFERANCE FROM PLAN BY PLAISTOW CONSULTAI'JS DATED 2-10-84 PLAr� SHOWIfNL SUBSURFACE cSEWERAGE_.__ - --� DISPOSAL SY'S TEKi AS -BU IL i LOCAT ICJN LOT6 BRIDGES LANE ;OWt\dER LYNCO REALTY Y T IUST WI E 5-7-84 SCALE 1= 40 PREPARED BY— j t FLYNN fiLTS50C P C' r r P 0, 5(-)/ J 6 9 PLA /s -)J(-' ,