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HomeMy WebLinkAbout0035 HUCKINS NECK ROAD - Health 35 HUCKINS NECK RD., CENTERVILLE A = 252 012 SIlI ADD i UPC 12534 ' No.2_ 1_ 5_Rq���s HASTINGS,MN M il Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Huckins Neck Rd �= Property Address '- I John & Eileen Pucillo Owner Owner's Name / information is required for every Centerville V Ma 02632 9/9/2015 . . page. City/Town State Zip Code Date of Inspection 1. Inspection results must be submitted on this;form. Inspection-forms may not be altered in any way. Please see completeness checklist at'the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M_Jones Title V Septic Inspection 1l Company Name 74 Beldan Ln. Centerville Ma 02632 Citylrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of ` Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/9/2015 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. ****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. t5ins•3113 Title 5 Official Inspection Form:Subsurface toeissalSystem-Page 1 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 35 Huckins Neck Rd Centerville is served by a Title V septic system consisting of a 1500 gallon tank, distribution box and 2 500 gallon precast chambers. The system was found to be in proper working condition at the time of inspection. 13) System Conditionally Passes: El 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John& Eileen Pucillo Owner Owner's Name information is Centerville Ma 02632 9/9/2015 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval.if pumps/alarms are repaired. 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 t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John& Eileen Pucillo Owner Owner's Name information is Centerville Ma 02632 9/9/2015 required for every Zip Code Date of Inspection page. City/Town State 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John &Eileen Pucillo Owner Owner's Name information is Centerville Ma 02632 9/9/2015 required for every State Zip Code Date of Inspection page Cityrrown 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? ® El information the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd l5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is Centerville Ma 02632 9/9/2015 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 'Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is Centerville Ma 02632 9/9/2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No vacant Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is Ma 02632 9/g/2015 required for every Centerville page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? size of tank Reason for pumping: routine maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 9/9/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 10/11/96 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok no leaks vented through the roof Septic Tank(locate on site plan): 2.5 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is Ma 02632 9/9/2015 required for every Centerville page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" 3" Scum thickness 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 10" How were dimensions determined? opened covers, took measurements 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 was cleaned at time of inspection and shouldbe done again every 2 years for proper maintenance. Inlet and outle tees were intact, water level was good, tank was not leaking and was structurally sound Inlet cover is on a riser. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John& Eileen Pucillo Owner Owner's Name information is Ma 02632 9/9/2015 required for every Centerville page. Citffrown 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 Elpolyethylene ❑ 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is Ma 02632 9/9/2015 required for every Centerville page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 011 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is Centerville Ma 02632 9/9/2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Type: " ❑ leaching pits number: ® leaching chambers number: 2x500 gal ❑ 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.): s.a.s.was found to be dry with a stain line 3"from the bottom. One chamber has a riser. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John &Eileen Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is Ma 02632 9/9/2015 required for every Centerville State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet_ Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately R t3 0 2 Zol A Z Z(, 25 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 15 of 17 t5ins-3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Huckins Neck Rd Property Address John& Eileen Pucillo Owner Owner's Name information is Centerville Ma 02632 9/9/2015 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 12'+ Estimated depth to high ground water: 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: pate ❑ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 — J Commonwealth of Massachusetts Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 35 Huckins Neck Rd Property Address John & Eileen Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 9/9/2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Fomx Subsurface Sewage Disposal System•Page 17 of 17 f r 0 Commonwealth of Massathusetts Title 5 Official Inspection Form A a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, �) use only the tab 1. Inspector: I T\ key to move your U cursor-do not Chad Hathaway use the return Name of Inspector key. VQ H.P.S. ,�y Company Name 1 Warwick way Company Address MIR Mashpee Ma. 02649 City/Town State Zip Code 1 774 274 2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the 04 information reported below is true, accurate and complete as of the time of the inspection. The inspection Lf Itwas performed based on my training and experience in the proper function and maintenance of on site G� sewage disposal systems. I am a DEP approved system inspector pu rsuant to Section 15.340 of R Title&(310 CMR 15.000).The system: w L= s ® Passes ❑ Conditionally Passes ❑ Fails t..:' •:t vy ❑'I Needs Further Evaluation by the Local Approving Authority C) E 8/10/11 Inspector's S' nature Date The system inspector shall Zmita 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. W t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis System• age 1 1 f Commonwealth of Massachusetts - Title 5 Official Inspection Form A a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. Cityfrown 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: 1500 gal tank with tees in good cond 2 500 gal leach pits drywith no standing water and no staining to indicate past failure 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 exfiitration 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r _7. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °w rY 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 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 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f i Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. Cityrrown 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'/a day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. City[rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM �` 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: none Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a " 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 48"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 24+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3.5' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 2'i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" 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 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required or every Centerville Ma 02632 8/10/11 f page. Citylrown 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 HoldingTank tank must be pumped at time of inspection) locate on site plan): ( P P P ) ( P ) 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments "Y 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. Cityrrown 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 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.): no D Box 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: 2 500 gal leach pits dry no staining t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8110/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I UJ 1 a b �i �86 a U U t5ins-09108 Tide 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °r 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12+ 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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: GNV 12' leach chamber 56" below grade bottom chamber is 70" down water is at 144" giving 64" seperation Before fling this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 35 Huckins Neck Rd. Property Address Pucillo Owner Owner's Name information is required for every Centerville Ma 02632 8/10/11 page. 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 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Division of Registration Office of Investigations r 100 Cambridge Street, Room 1509 ° Boston, Massachusetts 02202 617-727-7406 June 23, 1999 Gregory M. Galanti . c/o Galanti Transfer Service 3 5 Huckins Neck Rd. Centerville, Ma. 02632 RE: Docket No. EM-99-010: Miorandi Vs. Galanti Dear Mr. Galanti: The Board of Registration in Funeral Services has heard the facts of the above referenced complaint and has voted to issue you a cautionary letter for the above referenced complaint filed against you. Very truly yours, Helen Peveri Executive Director c. Donna Z. Miorandi C f''�f Z-5Z.—0 f Z -�0,6_v No. 9 L� `—' / V Fee ) �' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 01pprication for 10i5pood *pgtem Construction 3permit Application is hereby made for a Permit to Construct( )or Repair( Y<an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 3S-Ack �s,r�e� r� 6rr�jr f lan Assessor's Map/Parcel C eo*j„il'�1/e �7 _D('of Gryi Z Installer's Name,Add ss,and Tel.No. Designer's Name,Address and Tel.No. �� % CPO,0r 93 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(_61D Other TI pe of Building ie&sl 004eP No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow M9 gallons per day. Calculated daily flow er gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer hen applicable) r16J�4� Date last inspected: Agreement: The undersigned agrees to ensure the construction f the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue 's d PHeal Signed Date %D Application Approved by l Date_ 1V -4!`t Application Disapproved for the following reasons . Permit No. - f�— Date Issued 1 3 f,♦4 s. � � s �r�/•.(,ice 9 No. ' / Fee -„ h THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ' Z(ppYication for Migooal 6pgtem Construction permit Application is hereby made for a Permit to Construct( )or Repair( �n On-'site Sewage Disposal System at: • j. Location Address or Lot No. . Owner's Name,Address and Tel.No. Assessor's Map/Pazcel i E C ee;�eril,,Ae y-7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. _77/- 93 5F u, Type of Building: Dwelling No?of Bedrooms 3 Garbage Grinder(,C)IP t Other Type of Building A-sl OrlGG' No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow ✓30:' gallons. Plan Date Number of sheets Revision Date i Title � Description of Soil l ? Nature of Repairs or Alterations(Answer hen applicable) ,. Date last inspected: Agreement: The undersigned agrees to ensure the construction aidnr&Wjg)auwsof the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued .yet •s Ard o Health, Signed / Date Application Approved by - Date�/,:�g Application Disapproved for the following reasons i Permit No. '°^ f Date Issued oe�o r ————— ——————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS �-- BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(✓)on by klax L, Installer at S' 've- G irl% % has been constructed in accordance with the provisions of Title 5 and the for Disposal System.Constructio ermit No. 01 dated /��:+/� Date Inspect THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. — © — —————-—————-—— -— ————--——" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mtopaar *p!tem Construction Permit Permission is hereby granted toDlr L� f ©h✓`�/r�/��/®/1 to construct( )repair( ;7an On-site Sewage System located at No.# 3_: //y/,k%✓J.S Street and as{described in the above Application for Disposal`System Construction Permit. �' ��"' 11_!9� o. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below./' } Date: ' ,�'... � Approved 'riftty ' oard of Health i =.r TOWN OF B�ARNSTABLE/ L CA ON � � -f J�' rc LPJSEWAGE # VILLAGE ICe--ASSESSOR'S MAP & LO� INSTALLER'S NAME&PHONE NO. G� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 56®Q NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: DATE: 112L/ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any weUnds exist . within 300 feet of leaching facility) Feet Furnished by r � _ q �yr�L AC W 9A 4t TOWN OF MtNSTABLE LOCATION 3u��l�,y �2G� �� SEWAGE # VILLAGE G�h °/Pi' ASSESSOR'S MAP & LOTZ,5 L d7 Z INSTALLER'S NAME&PHONE NO. �DI'7`D� ��C4�57` 7 SEPTIC TANK CAPACITY /J'00 ��L LEACHING FACILITY: (type) YZ70 C&,w he,I (size) -r X 2 f X.1 NO.OF BEDROOMS 3 // BUILDER O OWNE G14 Lc h t� PERMITDATE: D—�f COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 0//0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1)9 mar Li Q rs' W � f 4 . CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL 1VURKS CONSTRUCTION I'I?It1111-I- (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 1012 01 , concerning the property located at 3 S/��G i�aS 1e eo/ eehj4ei°yi1e meets all of the p Y following criteria: `1 ,rt;arc no wetlands within 09 ic^_, of the nr000sed septic system. ere ire no private wells within i zt) ic^_t i the proposed sciatic system "hc observed.erottndty^icr lnhie �s ;s rcct �r ?renter 7e!ovv the bottom of the !enchin¢;artily %v in ' r _inn a ,u.e is �o incrcaSc in `lo a/-r ¢_ :n !jse proposed acre are no varinnc^s rcaneste^or,c^ded. SIGNED : ? DATE: L!CENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach n sketch plan or the proposed system. Also irthe licensed Installer posesms a certified plot plan. this plan should be submittedl. 19-1 W00 .0 1y a O 0 v Al Fes. 4A40 JN_ � I ti D% pro 8 I9Cg r F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEG PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION r•, Property Address: 35 HUCKINS NECK RD. CENTERVILLE � Name of Owner n/a Address of Owner: GALANTI Date of Inspection: 1/26/99 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02536 Telephone Number: (608)664-6813 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: X Passes Conditionally Pa s _ Needs Further v ation By the Local Approving Authority _ Fails Inspector's Signature: 0111 Date:1/26/99 The System Inspector shall submit a 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 The system all components pass Title V inpsection.Recommend pumping system every two years to prolong the system's usefuli life. t revised 9/2/98 Page 1 of 11 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/26/99 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: System passes Title V inspection 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. ND 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. NO 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). _ broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced NO 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 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: nla Date of Inspection:1/26/99 C. FURHTER 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 16.303(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 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 of 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 I 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 nLa_(approximation not valid). 3) OTHER nLa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/25/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined 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. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/25/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)j X 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 5 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/26/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):n& Total DESIGN flow: nLa Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):DLO Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: Wa gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) nLa Last date of occupancy: WA GENERAL INFORMATION PUMPING RECORDS and source of information: nta System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa_ gallons Reason for pumping: n& TYPE OF SYSTEM XSeptic 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: nta APPROXIMATE AGE of all components,date installed(if known)and source of information: New system was installed in 1996 Sewage odors detected when arriving at the site:(yes or no): MQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/26/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 3.6.. Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: Town Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: X Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nLa Dimensions: L10'6"H 5'7"W 5'8" Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: W 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: HE How dimensions were determined: Measured 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.) Septic tank and all components are structurally sound and functioning r r y,Recommend pumping system every two years GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: Wa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:-nLa Distance from bottom of scum to bottom of outlet tee or baffle nta Date of last pumping: n& 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.) n[a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/26199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n1a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n(a Dimensions: n& Capacity: n[a gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:jV& Alarm in working order:Yes_No_ NQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n(a DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) 1l� PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/26199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: nta leaching chambers,number: 2-600 gallon chambers leaching galleries,number: jVa leaching trenches,number,length: nta leaching fields,number,dimensions: nta overflow cesspool,number: nLa Alternative system: nLa Name of Technology: _nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The sas is functioning properly and is sturcturally sound. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. nLa Dimensions of cesspool: n& Materials of construction: nLa Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) IVA revised 9/2198 Page 9 of 11 ri SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/25/99 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) n/a a o c A o b Ail I� a3 revised 9/2/98 Page 10 of 11 V f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 HUCKINS NECK RD.CENTERVILLE Owner: n/a Date of Inspection:1/25/99 NRCS Report name: nta Soil Type: nLa Typical depth to groundwater: n/3 USGS Date website visited: nLa Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 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 Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS Maps and Charts - - revised=9/2/98 Page 11 of 11 ti- Division of Registration Office of Investigations 100 Cambridge Street, Room 1509 Boston, Massachusetts 02202 617-727-7406 CASE NAME: Donna Z. Miorandi vs Gregory M. Galanti DOCKET NO. EM-99-010 INVESTIGATOR: Arthur Carow Donna Z. Miorandi 367 Main Street Hyannis, MA 02601 Dear Ms. Miorandi: This is to acknowledge receipt of your complaint against Gregory M. Galanti of Galanti Transfer Service. Your.complaint has been assigned to the investigator above. Following our investigation of your complaint, a report will be forwarded to the licensing board and a decision rendered. You will be notified of the decision by the board. If you have any questions please contact the investigator assigned to your case at (617) 727-5946. Sincerely, Jerry C. DeCristofaro Assistant Chief Investigator DATE:11/24/98 771 After 5 days return to the Division of Registration Office of Investigations,Room 1509 Leverett Saltonstall Building NOV 2 4°9 8 !� 03 100 Cambridge Street,Boston,MA 02202 PB * METER Arthur Carow-Investigator ` 7078580 U.S. POSTAGE Donna Z. Miorandi 367 Main Street Hyannis, MA 02601 50%RECY®PAPER -fi rl g. ^i J !1 �t? t}iit i! 1, t 11 1 } 1 fdi •�t it "fret' 20%POSTCONSUMER v e -r �1' •.+.� + v'� I�:ifti.:.t-.tit! .!!!i.! lll.fli.!! l.Li.i !:. !li.tfi.. 2 111 11 1 HIM 1 1 11 1} 1 1111 111 1 111 1 111 1111 1 ti � E 1 O 0 The Town of Barnstable Department of Health , Safety and Environmental Services = t3ABMABLL Building Division r6 ,0� 367 Main Street,Hyannis MA 02601 , r��t► Office: 508-790-6227 Ralph Iyl.Crossen Fax: 508-790-6230 Building Commissioner Home Occupation Registmfion Q(; Date: Z c( o r Name• C `+�1'1 Phone #: Q( U -7 � 6Z Z 2 G. _n Address 7'tt� LC S �� 12 1� Village: � e✓L�<J( tv Type of Business: �2��-����� �f'�2�/�� _Map/Lot: 0l INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,.subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the `. activity shall not be discernible from outside the dwelling there shall be no increase in noise or.odor,no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal \� residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home.occupation shall be permitted as of right subject to the following conditions: r. . • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and v there is no outside evidence of such use. No traffic will be generated in excess of normal residertuai voltunes. �, • • The use does not involve the production of ofrensive noise. vibration,smoke,dust or other particular matter,odors,electrical disturbance, heat, glare, humidity or other objectionable effects. `� • There is no storage or use of toxic or lnnzardots materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such tse shall be met on the same lot containing the Customary Home Occupation,and not within the required front y.1rd. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary biome Occupation;other than one van or one . pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20,feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. �1 • -No sign shall be displaved indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be iududed. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: Date: Z l Homeoc.doc ti DIVaIrSION OF REGISTRATION OFFICE OF:INVESTIGATIONS w� yj � 3R617 727 7406 .''Ei ri.• r; +k d F?f ''i+pr#• {zzii`.iy t it` 2 f ''rys .z�a t .ice 't.�.- r Please complete this complaint form as fully as possible f`< This form must be printed in ink and be legible COMPLAINT ISSUED BY 60 z Name: 0 ' o Last Nam o F' t Nan Address: N b S eet aytime Phone Ins City State Zip Code Vemng Phone y 4 Business Name,Business Address :Professional I;icense#_. (if applicable) COMTLAINT.ISSUED AGAINST Name N e .` :L•. Address Number ...Stree o - Da a Phone CitI-Gy, State ~Zip Code License Number Name. he MT l _ Busines am ,ko Address: .. Number: Street 0/ Daytime Phone _ ity State Zip Code 'Professional License# Please check the trade.or profession that this complaint pertains to: Accountant Psychologist Aesthetician - Hairdresser Architect Health Officer �; Y F , Yz a w7 T,+rzt ear p a ,k `I.alld ap =Athletic Trainer §�� - i� may, , �> sc a Arclutect � x _ n r k " - Audiolog�st/Speech Pathologist �. °x<T;and Surveyor'` g., Barber Manicurist h Chiropractor - Mental Health Counselor ' Complaint Against School Marriage&Family Therapist Dental Hygienist Nurse . Dentist Nursing Home Administrator Drinking Water Plant Operator Occupational Therapist Electrician - Occupational Therapist Assistant Electrologists Optician Engineer - Optometrist Fire&Burglar Alarm Physician's Assistant Funeral Director Real Estate Appraiser Pharmacist/Pharmacy Real-Estate Broker/Salesperson Physical Therapist Rehabilitation Counselor Physical Therapist Assistant Respiratory Care - Plumber/Gas Fitter Sanitarian Podiatrist Social Worker Radio or Television Technician Veterinarian -Continued on other side- Please the the reason or a comp t Breach of contract '.Misrepresentation A,, Patient neglect'- " Discrimination' ` Drug or alcohol abuse Sexual misconduct t Unprofessional or unethical conduct Unable to obtain records -Failure to fill prescription properly Unlicensed Failure to return a deposit Unsanitary Conditions' . Inferior work or materials Other: Description of the Complaint: Briefly describe the incidents that led to your complaint and note the times and dates that events occurred. List the names of all individ s involved: - 9 4 _ ®. t>a i d ON J- �tb+xMr v;-r �t+.- < "`" a_--�a ai• -�„4d, may. .Q - 3 17z Attach'additional information needed to explain the details of your complaint. I Send copies;not the original,of any related documents. You will be sent an acknowledgementletter with the name..of the investigator assigned to. your case. - AUTHORIZATION FOR RELEASE OF RECORDS AND REFERRAL OF=COMPILAINT Your signature to this form;.or a photocopy thereof;authorizes the Division of Registration to >, (1)receive copies of all medical,dental and mental health records relating to your complaint,(2)refer your Y complaint to appropriate law enforcement authorities to investigate or prosecute.your complaint,and(3)conduct a a r, Y, - Y rel investtpatlon w u: * ref N sue; rfi a p '�""""J D G G ti- 24 nA h a s 59 a C o by i Please note that all-complaints are investigated to determine their factual basis..:.The act of filing a complaint does not-assure or 1 Ghat disciplinary action will necessaril be taken against`the licensee: . imP Y �P��3' Y a _ The bove information is.tru core d complete to the best of my knowledge Your signature Date y 4 W- -L Mail this form to: - - _ Office of Investigations,Division of Registration 100 Cambridge Street 15th Floor. t fi F Boston,MA 02202 ti e r� k > fM1'x e 937 C c k N ''4' „+ ♦ i 5's .t ..Cv.S,s 3 'rs . � _ Please check the reason for the com�7pnlaint: a.S.1 t. ,' Wa? a.tr :,Y!`..k'�1 .�.N` ` H ` ` r„J •�... .}Y x Breach of contract +` R tier '1u11SrepreSentSlOIl r ;+ =""Discnminatton `' >` Patient neglect z' Dru or alcohol abuse - g Sexual misconduct Unprofessional or unethical'conduct" Unable to obtain records - Failure to fill prescription properly Unlicensed Failure to return a deposit Unsanitary Conditions Inferior work or materials Other: Description of the Complaint - , Briefly describe the incidents that led to your complaint and note the times and dates that events occurred. List the es of all individ involved:. 9 9. G . .. . Q, a ,w,c •s+cr S-. o -- - .. Q , .. 0 p . - _ : Attach additional information needed to explain-the details of your complaint. Send copies,not the original,of any related documents. Yon will be.sent an acknowledgement letter with the name of.the investigator assigned to. your case. J AUTHORIZATION FOR RELEASE OF RECORDS AND REFERRAL OFCOMPLAINT. '' Your signature to this form ,or a photocopy tbeieof,-authorizes the Division of Registration to: (1)receive copies of all medical,dental'and mentaY health records relating to yopr complaint,,(2)refer your complaint to appropriate-law enforcement authorities to investigate.or prosecute your complaint,and_(3)_conduct,a preliminary investigation Please note that all complaints are investigated to determine their factual basis. The act of filing a complaint does not assure or imply that disciplinary action will necessarily be taken against the licensee. The bove information is-tru corre d complete to the best of my knowledge. m e Your signature61 Date Mail this form to: Office of Investigations,Division of Registration 100 Cambridge Street, 15th Floor Boston,MA 02202 ` 3 DIVISION OF REGISTRATION OFFICE OFtR-VESTIGATIONS .ft G•y xt �r,td y1�°��^4u�y� F `''"T.a L �,;, a,f+ .a-,.�'-_-, .• ';� #}�3 -. �:- - r : �'� Aa s'•xw "k^-bF•` R d� rka7.6 7 _. t � y .�r 1 727 7406 ease complete complete.tlus complaint form as fully as possible.: Jt. ' This form must be printed in ink and be legible COMPLAINT ISSUED BY Name 1 z+� ze Last Nam F' t Na c Mp.I. . Address: N b = Street ;©~ {aytune Phone 6D . City State Zip Code venmg Phone Y Business Name,Business,Address �' is Professional License# M (lf applicable) COMPLAINT ISSUED AGAINSTJ. 4 ` Name. �. O .. :' N e L >' 7 � Address. � Alt - N ber" 'tree v Daytime Phone City /' State 'Zip bode License Number Name. — ads .. x Busines Address. oU V Number.., ..,,Street e _,. (Daytime Phone City.' - State Zip Code Professional License# Please check the trade or profession that this complaint pertains to: Accountant Psychologist Aesthetician Hairdresser .. Architect Health Officer.. Athlette=Tramer'•j, .. r : . :� I;andscape Ar�chut ect "" `Audiologist/Speech Pathologist" '` '` ' =F'Lanc1 Surve orb- Barber „Manicurist Chiropractor Mental Health Counselor. Complaint Against School Marriage&Family Therapist Dental Hygienist Nurse . Dentist Nursing Home Administrator Drinking Water Plant Operator Occupational Therapist Electrician Occupational Therapist Assistant Electrologists Optician Engineer - Optometrist. Fire&Burglar Alarm Physician's Assistant Funeral Director Real Estate Appraiser Pharmacist/Pharmacy Real Estate Broker/Salesperson Physical Therapist Rehabilitation Counselor Physical Therapist Assistant - Respiratory Care Plumber/Gas Fitter Sanitarian Podiatrist Social Worker Radio or Television Technician Veterinarian -Continued on other side-