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HomeMy WebLinkAbout0003 HUCKINS NECK ROAD - Health 3.HUCKINS NECK RD., CENTERVILLE A = �I IN • UPC 12534 ' 0.2-153LOR q HAiTINOi�YN TOWN OF BARNSTABLE LOCATION 3 `"'1 uckXyx neck. roe, SEWAGE # _ VILLAGE CenT;.r✓A It ASSESSOR'S MAP& LOT aSI INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ,I LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 1 BUILDER OR OWNER bAA A W t 1 SOY, PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a q COMMONWEALTH OF MASSACHUSE TS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 3 Huckins Neck Road, Centerville, MA Name of Owner: Jay, Van&Dana Wilson Address of Owner: 14 Deerfield Drive Date of Inspection: July 19, 1999 Medfield, MA 02052-1318 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of'Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 251 Telephone Number: (508)862-9400 Parcel. 49 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system ✓ Passes Conditionally Passes Needs Further Evaluati By the Local Approving Authority ails i' Inspector's Signature: Date: July 24, 1999 The System Inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. NOTES AND COMMENTS r aDVEQ ALJC 1 9 1999 7000FBAB wrj D15 ARE .r 4AA,� ,.``�• revised 9/2/98 Page lofll Primed on Recycled Paper J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. -SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. . Indicate yes,no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined". explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. A _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) k r ' broken pipe(s)are replaced t4 obstruction is removed distribution box is levelled or replaced „ Y The system required pumping more than four 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 revised 9/2/98 Page 2of It SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 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 AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have detemmned that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. I Yes No Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. ® _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. x ' 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following.- The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n/a As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for conditions of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. The size and location of the Soil.Absorption System on the site has been determined based on: ✓ Existing information. For example, Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)]. ✓ _ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: n/a g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 4 Total DESIGN flow n/a Number of current residents: 1 Garbage grinder(yes or no): No Laundry(separate system) (yes or no): No ; If yes, separate inspection required Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last two yearg;usage(gpd): 1998-17,000 gals.; 1997-22,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd(Based on 15.203) Basis of design flow 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: -OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped on 719197-per treatment plant System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system _ Single cesspool ✓ Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval -Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Unknown Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage; etc.) SEPTIC TANK: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: 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: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: None (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) } Property Address: 3 Hucklns Neck Road, Centerville, AM Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: 4 Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: 1 -6'x 6'-block Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.) The overflow cesspool had 1'of water on the bottom. There were no signs of failure. The bottom to grade was 9'. CESSPOOLS: ✓ (locate on site plan) .Number and configuration: 1 Depth-top of liquid to inlet invert: -- Depth of solids layer: 1' Depth of scum layer: 4" Dimensions of cesspool: 6'x 6' Materials of construction: Block Indication of groundwater: None inflow(cesspool must be pumped as part of inspection). Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) The liquid level was even with the outlet pipe. The bottom to grade was 10'. PRIVY: None (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.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 Map: 251 Parcel: 49 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 5ltdcr 4 a� a7 " a' revised 9/2/98 Page 10oftt H SUBSURFACE SEWAGE' DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 Huckins Neck Road, Centerville, MA Owner: Jay, Van&Dana Wilson Date of Inspection: July 19, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 40+/- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers Used'USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using the Barnstable Topographic Map and Water Contours Map, the maps were showing approximately 40' to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11 1 1 fj,Al ai SENDER: I also wish to receive the ;o ■Complete items 1 and/or 2 for additional services. following S@NiC@S(for an y ■Complete items 3,4a,and 4b. w r Print your name and address on the reverse of this form so that we can return this extra fee): ,y. card to you. d d ■Attach this form to the front of the mailpiece,or on the back if space does not 1.El Addressee's Address i permit. 2 El Restricted Delivery d ■Write"Return Receipt Requested"on the mailpiece below the article number. . ry Cl) Y ■The Return Receipt will show to whom the article was delivered and the date Consult postmaster for fee. — delivered.;_ p 2- 0 3.Article f Addressed to: 4a.Article Nu b r� 7 D " 1 m a 4b.Service Type E ; Irwin Jacobs �, 0 81 WilloW Run Drive ❑ Registered [ Certified rn ❑ Express Mail El Insured to Centerville , MA 02632 y w y. ❑ Return Receipt for Merchandise ❑ COD CC 7. Date of Delivery _M 5.Received By: (Print Name) 8.Addressee's Address(Only if requested Y H and fee is paid) ¢ 6.Signatur . (Ad essee or ent) 'o X 41PS Form 3811,December i��s-98-B-o229 Domestic Return Receipt 1 UNITED STATES POSTAL SERVICE First-Class MailPostage&Fees Paid USPS Permit No.G-10 •Print your name, address, and ZIP Code in this box • BENNETT &O'REILLY, INC. 1573ain Street P.O. Box 1667 Brewster,MA 02631 • �.::..z•�.��...�.,., II{���,�f�l�li.,��li�„Ali{���I�I{...Ii.�I��,Irfh�l���ll�l��l ` a SENDER: I also wish to receive the follow- z ❑Complete items 1 and/or 2 for additional services. ing services(for an extra fee): H Complete items 3,4a,and 4b. ❑Print your name and address on the reverse of this form so that we can return this y > card to you. 1. ❑ Addressee's Address V ` ❑Attach this form to the front of the mailpiece,or on the back if space does not permit. 2. ❑ Restricted Delivery N r ❑Write"Return Receipt Requested"on the mailpiece below the article number. c ❑The Return Receipt will show to whom the article was delivered and the date a o delivered. Id a 3.Article Addressed to: 4a.Artr`2`2 d �q- 1O E 4b.Service Type ❑Registered Certified q u)l Marilyn F. Fawkner ❑ Express Mail ❑Insured E'� 119 Annabelle Point Road ❑Return Receipt for Merchandise ❑COD aCenterville ,. 02632 7.Date of Delivery w z U-17 T 5.Received By: (PrintNamej 8.Addressee's Address(Only if requested and c w fee is paid) t 6.Signature(Addressee or Agent) y IPS Form 3811,December 1994 �� Y�� t 2sss-ss-a-ozz3 Domestic Return Receipt UNITED STATES POSTAL SERVIOCME' First-Class Mail -PoslaatA.Eees-Paid p m 111 t PermL�LQ_940- ................... ............................... a........ ........................... .......................................................................... ....................... .d - ,! Print you rhe,198di4s, and ZIP Code in this box * BE I NNETT& O-REILLY, INC. 1573 Main Street P.O. Box 1667 Brewster, MA 02631 CE ,� ................................................................................ .................................-------------------- ................................................................................... Ar-?'Se f,--? a; SENDER: I also wish to receive the :a ■Complete items 1 and/or 2 for additional services. following services(for an 0 ■Complete items 3,4a,and 4b. d ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. > ■Attach this form to the front of the mailpiece,or on the back if space does not 1.❑ Addressee's Address •2 ` permit. d ■Write"Return Receipt Requested"on the mailpiepe below the article number. 2.❑ Restricted Delivery N .t. ■The Return Receipt will show to whom the article was delivered and the date Consult postmaster for fee. delivered. t p C 0 3.Article Addressed to: 4a.tdcle nr2 1-2 Ll0 E Jacob Kesten 4b.Service Type 0 5 0 west 9 6 t h Street El Registered Certified I=MW New York , NY 10025 ❑ Express it �IRsured c ❑ Return R eip for Merchandise ❑ COD 7. Da `o 5.Received By: (Print Name) 8.A dressee's ddress(Only if requestedand fee is paid) 6.Signatur (A dr�see o' X �[�1 21 PS Form 3811;D6cember 19 1 i 595-98-B-0229 Domestic Return Receipt UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid usPS Permit No.G-10 O •Print your name, address, and ZIP Code in this box • d Q G BENNETT & O"REILLY, INC. Q 1573 Main Street Q f P.O. Box 1667 Brewster, MA 02631 ftf,,,,,i',t,if,►„il,,,�l'it„�i,ii„+l „1,,,i,tt,►t,,, i, „1 11 ci SENDER: I also wish to receive the L3 ■Complete items 1 and/or 2 for additional services. following services(for an N ■Complete items 3,4a,and 4b. d ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. v d ■Attach this form to the front of the mailpiece,or on the back if space does not 1.❑ Addressee's Address •2 permit. 2.❑ Restricted Delivery a)� ■Write"Return Receipt Requested"on the mailpiece below the article number. ry N r ■The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. fl 0 3.Article Addressed to: 4a.Article v � a OPeechee Heights Associatio 14b.SffyieeType 0 c/o Tom Nutile , Treasurer, Registered Certified M, y P.0 Box 23 ❑ Express Mail Insured y 131 Yacht Club Road El Return Receipt for Merchandise ❑ COD c Centerville , MA 02632 7 W-Qofaivery 0 Ir 5.Received By: (Print Name) r' &P(d es�$ 's Address(Only if requested Y wI C and fee Y� aid) cc cmc 6..Signat c� (N d ~ 0 ;X b IN 2 PS Form 3811,December 199 +()f� jl� . �92595-9s-B-0229 Domestic Return Receipt UNITED STATES POSTAL SERVICE , First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Print your name, address, and ZIP Code in this box • BENNETT& OREILLY, INC. 1573 Main Street P®. Box 1667 Brewster, MA 02631 111 I III III liI'l till II Ili III II'111141111 Ili I III Ill,llisII1111It SENDER: .� I also wish to receive the follow- Z ❑Complete items 1 and/or 2 for additional services. ing services(for an extra fee): a) Complete items 3,4a,and 4b. C ❑Print your name and address on the reverse of this form so that we can return this y > card to you. 1. ❑ Addressee's Address d ❑Attach this form to the front of the mailpiece,or on the back if space does not permit. •. . 2• ❑ Restricted Delivery N ❑Write'Return Receipt Requested°on the mailpiece below the article number. ❑The Return Receipt will show to whom the article was delivered and the date a p delivered:' .� v 3.Article`Addressed to: 4a.A NMKNLN 1 as E '. 4b.Service Type 0 Raymond J .. Kennedy ❑ Registered >&ertified N = 95 Annabelle Point Road ❑Express Mail ❑Insured o --' Centerville , MA 02632 r ❑Return Receipt for erchandis ❑COD 7 Date of Deli a z o'' 5.Rec 've _,.,;,( rin N ) 8.Addressee's Address(On y if requested and ¢ fee is paid) M t— c 6.Signature(Addressee or Agent) 2595-99-B-0223 Domestic Return Receipt EEi i i f�ii! it �t i iE=. First-Class Mail UNITED STATES POSTAL SERVICE Postage&Fees Paid LISPS Permit No.G-10 • Print your name, address, and ZIP Code in this box • BENNETT & O°REILLY, INC. 1573 Main Street P.O. Box 1667 Brewster, MA 02631 +t` J j I �'$ fill""IIII III IIIII III Ill III III If l It l l ii Lll.I:lf11LI�11I�19-u.i/ � _. _ I T 1A1 M v SENDER: I also wish to receive the follow- 0 Complete items 1 and/or 2 for additional services. ing services(for an extra fee): y Complete items 3,4a,and 4b. _ ❑Print your name and address on the reverse of this'form so that we can return this y card to you. 1.❑Addressee's Address V ` ❑Attach this form to the front of the mailpiece,or on the back if space does not permit. 2. ❑ Restricted Delivery N r [I Write'Return Receipt Requested°on the mailpiece below the article number. ❑The Return Receipt will show to whom the article was delivered and the date a p delivered. 'y v 3.Article Addressed to: 4a.Artir%4112 d E Kenneth R. Amesbury- 4b.Service Type m 0 105 Annabelle Point Road ❑Registered (Certified M LU Centerville , MA 02632 ❑ Express Mail Insured S ❑Return Receipt for Merchandise ❑COD a 7.Date of Delivery, w -a p 5.Received By: (Print Ka ) 8.Addressee's Ad ess(Only if requested and c >°, ': i + tit•iiiii itit i iiit iiiI ii ti i iiIIi i1iiI i'i N m PS f iReceipt UNITED STATES POSTAL SERVIC�.,�� First-Class Mail Pottage&Fees Paid uses Permit No.G-10 ....................................................................................................................................................................................................................................................... 0 Print your narneraddoss, and ZIP Code in this box 0 BLININETT & UREILLY, INC. 1573 Main Street P.O. Box 1667 Brewster, MA 02631 .................................................................................................................................................. ....... ................. d SENDER: I also wisfj to receive the follow 'w ❑Complete items 1 and/or 2 for additional services. ing services(for an extra fee): N Complete items 3,4a,and 4b. ❑Print your name and address on the reverse of this form so that we can return this y card to you.-, 1. ❑Addressee's Address d ❑Attach this form to the front of the mailpiece,or on the back if space does not permit. 2. ❑ Restricted Delivery N ❑Write'Return Receipt Requested"on the mailpiece below the article number. ❑The Return Receipt will show to whom the article was delivered and the date o. p delivered. ' 3.Article Addressed to: 4a.Acticle Nt yb M 221 orv� Ej CL E Leonid & Maya SimanovSky 4b.Service Type d rn 7 7 Willow Run Drive ❑ RegisteredSCertified W Centerville , MA 02632 El Express Mail ��❑Insured y ❑ Return Receipt for Merchandise ❑COD a 7.Date of D li z .—V >. 5. eceived By: (//Print Nppe) S.Addressee's Address(Only if requested and ¢ e o),ld J!ryjG�(4 d L4s fee is paid) t 9 6.Signature(Addressee or Agent) j'06>8 r N form 3811,December 19 4 (�� �� 2s95-99-13-0223 Domestic Return Receipt UNITED STATES POSTAL SERVICF First-Class Mail � Postage&Fees Paid ^" USPS c•1A ��^ Permit No-G-10 • Print you.r name, addr: ss, and ZIP Code in this box • BENNETT& O"REILLY, INC, 1573 Main Street P.O. Box 1667 Brewster, MA 02631 :11111Il loll Ill IIIII if III IIIIII Ill 11 fill I Ill SENDER: I also wish to receive the ■Complete items 1 and/or 2 for additional services. following services(for an V) ■Complete items 3,4a,and 4b. am ■Print your name and address on the reverse of this form so that we can return this extra fee): n card to you. 01 a) ■Attach this form to the front of the mailpiece,or..on the back if space does not 1.❑ Addressee's Address •> permit. 2.El Restricted Delivery d � ■Write"Return Receipt Requested"on the mailpiece below the article number. ry to Y •The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. 0 3.Article Addressed to: 4a. le pinrifger� Y C °L Irwin Jacobs Service Type 7 U 81 Willow RUn Drive ❑ Registered Certified cc N Centerville , MA 02632 Registered Mail Insured S w ElReturn Receipt forperchandi5t ElCOD 24 0 7.Date of Deli o °>' 5.Received'By: (Print Name) 8.Address e' A dres ( ly if requested ,� and fee is aid) W L Sign ure: (A ressee or � [ oXll �' PS or 80 December 1r994 9 98-B-0229 .Domestic Return Receipt UNITED STATES POSTAL SERVIC \�'�S �< =First=Class-Mail `r pm �, z Postage=&=Fees Paid USPS-----' ;- .fig.„, o.-.,�• Permit-No G-1,G"� f7 - — • Print your na• ;�2iarp s, and ZIRCede�nrthis-box• SENNETT& O"REILLY, INC. 1573 Main Street P.O. Box 1667 Brewster, MA 02631 1.