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0481 MAIN STREET (CENT.) - Health (2)
L481 MAIN STREET, CENTERVILLE _ `7 A=208.085.004 C LDSED i li Arm e h, i No. 42101/3 ORA ESSSELTE 10% U& O © O O i1 t f F aC ree o� �6� k r l I � 4 r C i d R a ° J q i J a t Town of Barnstable Barnstable BARNSTABLE ; Regulatory Services Public Health Division ASAmpAcaUty 'DrEc N►►�° Thomas McKean,Director , 1 111., 200 Main Street 2007 Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 February 7, 2017 Commonwealth of Massachusetts Division of Professional Licensure Board of State Board of Examiners of Plumbers and Gas Fitters 1000 Washington Street Boston, Massachusetts 02118-6100 RE: 481 Main Street, Centerville, MA TO WHOM IT MAY CONCERN: This is to acknowledge that I have no issue with Willard Smith's requested variance to connect cast iron or copper per code to the existing PVC vent with all waste, water and vent pipes up to the ceiling of the new %2 batch at the location of 481 Main Street, Centerville, MA Sincerely, r A. McKean Director, Public Health Division J:\LETTERS\Let STATE Plumb Board 481 Main St Cent Feb 7 2016.DOC Crocker Sharon From: Crocker, Sharon Sent: Tuesday, February 07, 2017 3:54 PM To: McKean, Thomas Subject: 481 Main St, Centerville FYI Willard Smith was in today. He is applying to the State for a State Plumbing Code Variance. I have some paperwork for you regarding this that I'll put into your box. He will be emailing you a letter from our Plumbing Inspector, Larry, and a request to write a letter of support to the State. Sharon /l i 1 Commonwealth of Massachusetts Division of Professional Licensure Board of State Board of Examiners of Plumbers and Gas Fitters 1000 Washington Street • Boston • Massachusetts • 02118-6100 VARIANCE FROM STATE PLUMBING CODE PRE-INSTALLATION $86.00 application fee payable to "Commonwealth of Massachusetts" DO NOT USE THIS APPLICATION IF PLUMBING WORK HAS BEEN COMPLETED PLEASE PRINT CLEARLY (Sectionl)APPLICANT INFORMATION: Applicant Name: Firm Name(if applicable): Date: State Legislative Leaders Foundation Feb 8, 2017 Title or Position with Firm(if applicable): Type of Work: Alison Bressi, Finance Manager New Construction: 0 Renovation: Street Address: City/Town: State: Zip Code: 481 Main St Centerville MA 02632 Cell Phone: Work Phone: Email: (508) 360-1662 (508) 827-7233 1 finance@sllf.org ALL OF THE FOLLOWING ITEMS MUST BE INITIALED. IF LEFT BLANK.. THE FORM WILL BE DEEMED INCOMPLETE AND WILL NOT BE ACCEPTED. 1.I have included with this application written documentation that the local Board of Health has been petitioned INITIAL BELOW regarding this variance request.*(Variance requests for City of Boston must include petition to Inspectional Services) Note:No Board of Health petition is required for buildings owned,used or leased by the State of Massachusetts. 2.1 have included all necessary supporting documentation regarding this variance request. INITIAL BELOW 3.1 have included a non refundable check for$86.00 payable to the Commonwealth of Massachusetts. INITIAL BELOW Note:No payment is required for buildings owned,used or leased by the State of Massachusetts. 4.The unusual or extraordinary circumstance or established hardship that warrants special terms or conditions is INITIAL BELOW clearly stated in(Section 5)on the second page of this application 5.1 understand that this variance request is for one instance at the location information stated in(Section 3) of this INITIAL BELOW application. INITIAL BELOW 6.1 certify that the plumbing work relevant to the information stated in(Section 5)has not yet been performed. * "Additionally,any response by the Board of Health or Health Department must be provided,however,the Board may waive this requirement so long as the petition was made in a timely manner." ;a TEL: 61,'7-727-9952 FAX: 617-727-6095 TTY/TDD: 617.727.2099 http://www.mass.gov/dpl/boards/pl (Section 2)OWNER OF THE PROPERTY WHERE THE VARIANCE IS LOCATED:(Please leave blank if information is the same as in Section(1)) Individual Name: Firm Name if applicable): State Legislative Leaders Foundation Street Address: City/Town: State: Zip Code: 481 Main St Centerville MA 02632 Cell Phone: Work Phone: Email: (508) 360-1662 1 (508) 827-7233 finance@sllf.org (Section 3)LOCATION OF VARIANCE:(Please leave blank if this information is the same as in Section(2)) Name of proposed or current occupier of the building: Street Address: City/Town: Zip Code: (Section 4)ADDITIONAL INFORMATION: Plumber's Name(if available): Plumbing Firm Name(if available): Work Phone: Glenn Raymond E F Winslow Plumbing & Heating (508) 399-7778 Name of Plumbing Inspector: Date Inspector was informed of this Variance Request: Larry Lamoureux Feb 3, 2017 Plumbing Code Section(s)Relevant to this Variance Request: Has Plumbing Work Begun at the Location of this Variance Request: Yes: No: Date Work Began: (Section 5)VARIANCE INFORMATION:(Please explain in detail the established hardship relative to this variance request) Variance requested Requesting a variance to connect cast iron or copper per code to the existing pvc vent, with all waste, water and vent pipes up to the ceiling of the new 1/2 bath. Otherwise the closest cast iron vent is in the attic approximately 25' down the hall and 2 floors above the 1/2 bath. History of the property In 1881, Howard Mason built the property known as 'Fernbrook', a Victorian estate situated on 17 acres on Main St., Centerville. The grounds were designed by famed landscape architect Frederick Law Olmstead, who designed the "Emerald Necklace," Boston's series of public gardens, and New York's Central Park, among others. After the death of Ella Marstion in 1931, Technicolor inventor Herbert Lakmus and his wife, Natalie, moved in. In 1941, when Disney's Fantasia opened in theaters, Herbert and Natalie Kalmus entertained a number of Hollywood celebrities there, including Walt Disney, Cecil B deMille, and Gloria Swanson. In the 1960s, Fernbrook again switched hands when it was given over to the Carmelite Order. Cardinal Francis Spellman frequently used Fernbrook as a retreat where he hosted both John F Kennedy and Richard Nixon. Property used since 1990s as a bed and breakfast. In November 2016, State legislative Leaders Foundation, a public charity, purchased Fernbrook to be used as commercial office facility. Please see attached Cape Cod Times article "If walls talk, opulent historic inn offers some serious name-dropping" posted July 16, 2016 for further discussion of the property. By checking this box - I hereby certify under pains and penalties of perjury that the information entered on this application request, including supporting documentation,is true and accurate and is filed in accordance with Chapter 142,section 13 of the General Laws and 248 CMR,the Massachusetts State Plumbing Code. I certify that all work performed prior to this request for a variance meets the requirements of 248 CMR and that I am only seeking a variance for work that has not yet commenced. I also certify that I understand that this is a request for the Board to allow an exception to the requirements of the Massachusetts State Plumbing Code�d`d not constitute an appeal of an inspector's decision. Signature of Applicant Date: i CAP)PI D TIMES If walls talk, opulent historic inn offers some serious name-dropping Saturday Posted Jul 16,2016 at 2:01 AM Updated Jul 22,2016 at 2:34 PM By Ethan Genter ......................................... Follow The historic Fernbrook Inn of Centerville,built in 1881, is as opulent as its guest list. It has had some notable owners as well,beginning with Howard and Ella Marston. Next, Dr. Herbert Kalmus purchased the inn and named it Fernbrook. Kalmus, the co-founder of Technicolor,may be more known to Cape Codders for the beach in Hyannis that bears his name,but the M.I.T. graduate bought the inn and with it hosted Walt Disney as he was working on Snow White, says Mary Ann English, the current owner who bought the inn in 1997. "Kalmus was known to have a celebrity contingent coming and going at any given time at Fernbrook; in fact,when Disney's Fantasia opened in theaters in 1941, Kalmus and his first wife, Natalie, hosted a number of celebrities at the estate including Clark Gable and Cecil B. DeMille,"Ann Luongo wrote in a story on the inn for Cape Cod Life. The movie heritage continued in the family when Kalmus' stepdaughter Cammie King went on to play Bonnie Blue Butler in "Gone with the Wind." The home's grand,appearance fits its guest list. Clocking in at over 6,700 square feet, the home is an exquisite update on the Queen Anne-style shingle home. English has practically renovated the entire estate, while holding onto many of the classic elements. The ballroom off the very large kitchen is one of the most impressive parts of " the home. Its vaulted cathedral ceiling must have taken quite some time as it is , painted in several different shades of blue that all blend together. The floors are wood and complement the great and handsome mantelpiece, adorned with the inn's name and a pair of carved dragons above the fireplace. A set of doors leads to an Italian-inspired terrace,which is just a few stairs away from the 50-foot lap pool. After Kalmus, the estate was picked up by New York Cardinal Francis Spellman. Spellman would use the home for summer retreats and was known to host the Kennedys. "Spellman had connections with several members of the Kennedy family. He was a friend of Joseph Kennedy, Sr.;he presided over Ted Kennedy's first wedding in 1958; and when Spellman died, Robert Kennedy attended his funeral. At Fernbrook, Spellman also hosted President John F. Kennedy and his wife,Jackie, on several occasions,"Luongo wrote in her story. The Cardinal Room, one of the home's guest rooms,was fashioned after a chapel that Spellman had used at the home, English said. The room has a majestic air to it, and again has a European renaissance feel, with the fleur-de-lis hanging in the g g room's stained-glass windows. The home is built for entertaining. In addition to the pool area, there is a sweetheart garden, as well as an outdoor tented dance floor and guest cottage. The lawns were designed by Frederick Law Olmsted, better known as the "Father of American Landscape,"who also had a hand in the designing of Central Park and Elm Park in Worcester. Chock full of history, the home leaves its guests with a sense of awe. That may be due to the sheer size of the place, or perhaps its height. With three levels, the upper balcony is likely one of the highest places in the village. English has gone through painstaking remodeling to update the home, all while keeping:it in historic style. And the star power continues -- Bill Murray has been said to have stayed at the home while on a trips to Martha's Vineyard. 1{Y'4'. 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S� a t fN r 7 'I I Y s. i f s 'Off , 3� a y *5jq f Y ski 4 i li � Ny a uwI ✓ r `' .S j �L 1 wayl )QT MEANS F a 4-4 fp � ' iSthl.> U1L sr ° fix'°"jf sy Fa ! 10 w 4 I � s�i 3g a d W A k✓i �,!� i ( .,r�'.l` Via. L+ 1 f Z.2X' I � � r P > f I (� E..i P 4 1 l"u { M15 § LI f w e� r� x e.. ±,PIR r k. i s f' x , t t. F s E I 1'. g i j� I x 2 y r a�9R i 1 1f i t:. I 4 Y i .l�s ? ,4 y r g�� Mrs q�No... �. .f F>$.. .......... THE COMMONWEALTH OF MASSACHUSETTS O RDW. ..L& H � 1 .. ......0 F..... ... ... .....'�-� C Appliration for Biivoottl Works Tonoirur#ion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 3 - ....: ........- .�1� -- !(.:+ ._:_.. .............................................. ....................................---------... o aU n-Address or Lot No. ��'�1 n.. G... ...:��.. ----------------------- .�� p Owr�}er -------•--•------*-----•-Address � Installer Address Type of Building Size Lot.: _S;!1.........Sq. feet Dwelling—No. of Bedrooms.._................:....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ______________•_-_-_____-_------_ . W Design Flow........................... a......._._.gallons per person per day. Total daily flow.......77©...................... gallons. WSeptic Tank—Liquid capacityZ5!?Lgallons Length i/��®.°'.. Width........... Diameter..._...--•-_- Depth..?�!`l' x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..__..........._....sq. ft. Seepage Pit No...-____-3_.__..-- Diameter.__....fo Depth below inlet... Total leaching area_Q_9®........sq. ft. Z Other Distribution box (v) Dosing tank (y ) Percolation Test Results Performed by.... ................ Date_6.: -2sG Test Pit No. 1................minutes per inch Depth of Test Pit.....___Z......-.. Depth to ground water........................ Test Pit No. 2.......9.....minutes per inch Depth of Test Pit..... Depth to ground water.................... a ........-................................................. O Description of Soil--•--•2 -T®'� C0v2SC.:�.5�4!�!ty.�. �! ,y: Wit' °�`v .BAN ... ..---------•-•----.._..-- •---•--------------•---••••-••---------•--•------------••-•---------..........•. ---------------------------------------------------------- ----------------------------------------•-----•--•••-- --------------------------------- N ture of Repairs or Alter—Answer when a lic�ble.----- ---- U P P ` �. •-------------------- �r -- ----•--- ---•R-ew..--•.... .....-•�. -----------------------0.•---- eement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL% 5 of the State Sanitary Code e rsigned further agrees not to place the system in operation until a Certificate of Compliance has been iss o�,t 411th.Sine .•..... ......c. Application Approved By---- • . . . .......... . ........ ...................•---.... -•••-•• � to - "Dto Application Disapproved for ?,011io-_ reasons------------------.. ......................................................................................... --------------------------------•-----•--------------•-------- ------------- --- ------------......------ c Date Permit No..... ........ Issued-.... �...7 T... ate `No... KuR... .... ............ THE COMMONWEALTH OF MASSACHUSETTS H Lj ...................... .... .. .. F. 7V.M ..... . . ... ..... .. ...... Apphration for Diiipaaal Workii Tonstrurtion Frrinit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ....4.4 W-4..S.7...........C.�....... . .. ............................................... ........................... WORI...........?_1 Location-Address or Lot No. .........6 ...... ... ..L4.4-d........................................... . .................................................................................................. Ow5,r Address Installer Address U Type of Building Size Lot................ .........Sq. feet Dwelling—No. of Bedrooms...... ...................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons____________________________ Showers Cafeteria P4 Other fixtures Design Flow..............................1� flow..._.._............. gallons per person per day. Total daily 7,_-1...........................gallons. "y 1:4 Septic Tank—Liquid capacity.M!;��R.gallons Length. .... Width.- . .:4- -7 . ......... Diameter................ Depth................ Disposal Trench—No..................... Width.....__............. Total Length.................... Total leaching area...................sq. f t. Seepage Pit No.......... ........ Diameter....... Depth below inlet---A,............. Total leaching arealy?........sq. ft. Z Other Distribution box ( v) Dosing tank ( ) P-4 A.-WZ 5,41 Percolation Test Results Performed by.-..,"- 4!/ i Date..:�-.-_/ *......7> �_l ---------------------i-----. .............. ............... Test Pit No. I.......9.....minutes per inch Depth of Test Pit-__--!.- Depth to ground water........................ fsl Test Pit No. 2........Z!Z_.minutes per inch Depth of Test Pit------ ........ Depth to ground water.................... P4 0 Description of Soil....... ,V .; V......................... ........... ............ ................................. 111"Al /I ," �, .......................................... U ...........;:.............................................................................................................................................. ......................................................................................................... ... 0 ........................... a ion§—Answer w ap 414-1 - U N4ture of Repairs or Alter ti A ver when lic#e....... .� .... ................................................ .......... .—W....4....R..Q , W, .115-aJ7.............. .......*..........*..................................... r 2ement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITA I.E 5 of the State Sanitary Code—�e the boa further agrees not to place the system in operation until a Certificate of Compliance has been issue4 e boXyo-pf hea h. Signe .......... ...... ........ , .... ... ......I...... . . .............. ........ ..................... Application Approved By. .... ...I. ..... ......................... e ZN te Application Disapproved for follo g�',,reasons:.. ............ .............................................................................................. ..................................... . ......... . ...............................z........... 0110 Date PermitN .. .............. .................... o.. ssuedL..... ........ .............. ate THE COMMONWEALTH OF MASSACHUSETTS 'BOARD QF HEALTH ................. Trrtifiratr of Toutpliattrit THIS I CERT ,/T1h a the ual S Di ste/ t ted or Repaired ......... ozir_.Z.....e,I................................................ by ....... Installer at ........... .6..... ... ............................................................................................................... has been installed in accordance with the provisions of TI 5 of e Sanitary d as pfftd in the a lication for Disposal Works Construction Permit No..... .............. pp dated---- -- - ------------------ THE ISSUANCE OF THIS �ERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE. THE SYSTEM WILL FUN..C.. T..I..O. . .7 CTORY. DATE.. . ...... Inspector. .. --- ................................................... THE COMMONWEALTH OF MASSACHUSETTS qy�OAR .............70. 0 F.... OKI ......... .................... ......... N o.......Z........ FEEA0....... V7 rutit 11to Permission is hereby ranted. ....... ....... ................................................. to Construct or Repair an Individual Sewage Disposal System atNo............................................................................ Street as shown on the application for ispoal Works Construction 7 d..... DATE......................q. Sp .S.......................... -------------- Board Of e Ith V FORM 1255 A. M. SULKIN, INC.. BOSTON AMMIP""7 n ///f Arm i I i3 tN 6ws,.v a7zl VE- EA5E`1�.V ;5• `- 31.4 70.c= .SKET•-1� PL�u .4ri_nu� I.U `_N'�ivf_:.,_,,�y:•. �340 P - -�:.L { l \ `� �, �T 5 5[1/f -OT y :J ._ �:V.1/ N'-Q•\//� ''J l �_ •` l- ,PA?K,v�\. \ .� ,QJn••'.=0 Gam" rn,, air - •� :��.t. ;c! �.-- {� '@� ��1, ,~"-. .. •...•... - D..rE: _1y-_vsj,3� �r>`-_- -- ..,'..=a';�a�'--.,=1�4 w,. _ rA I K-15.-1N�� Ir Q.S.T.-. .cO �' z�•o ,_ � ........ .. .. -.-. ..._ - _ _. _ .. -. �a 2l vx i ! 4 Uz.S `{ y . .. ` PAY.Zo_- , - ALL CAPZ eN "uEraLP 1�4 .41 1 _ ' 4 Lori / �[N^1"y<]1LC. ! =`k<Q�•.r. � 43:5 - -..�. -..�.. .r..•. .- 1... - ' � - .. . �. r- .r � [ -r. j r - 20" L r -y' � r I TEST P.r P_57/•� . . TEST r 1i ?5-44 M��e -S•f-S� :rlao_ ;a_St M Gasp e r aP H 25Q0' .7T Plr tG�. w/r. T.:oNcou Vir. 7 M`KEA � � a D.A vo. � NG.x[4r�.r2. ,novvh�cP_ SQM=. C{eoo, � M Tr otl..:,:' G x • xQE.?e-g 2 M!Al.Pg� i" SdM� � J. �._ ---- _. ... . U'y,4,`�- PiT58�' �.'��,'�----�----� 3j 8' 32.0 _ I AE S I c,A! 0A Q w/z'SroNE z7.o 19.0 TP Tpz•1 TP3 O I.3cb KG.aM5 TO Pi TA� no ES%/MATZO rLOW 77ol .�.. 35.1- �iG 2�.4 G� . . <, C.ZFAS� An 5o Ji ISouE Ti4L.C/a�4Clir Z)Z!/. G7:P0. �.. . ; Y f3ouey :yEolun I ;nlo.oP P,rS: 31 I -r O n ALL'A 3o.z 5Au0 !^ yx i. MA�i :NOTE Y t . MEtii tit t `/ .Nw:SrST«q :7 .3LEARR y�irTN CKIST�i�(y: SEivCQ L/�Jer ; . . . 1 zf — : . - _ � T I t / -TJ y- � •'.-:,-•w, - _ .��'�-�+.'•:-,-"'.is:"".--..""�'...;�.•� w'�mow:� ,. x�+:...:.:.�ar'i _ .�..-_-. - - •. - � - .-- �. . -^-� -- '� ; -' ^� I j& tl v TOWN OF BARNSTABLE _LOCATION S SEWAGE 3 VILLAGE C 0211:7 AVIIL Q ASSESSOR'S MAP & LOT . /0-r4 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY Q V2— LEACHING FACILITY:(type) 3 4�- X P /0l5 (size)_ NO. OF BEDROOMS_ _PRIVATE WELL OR PUBLIC WATER fOzvT, BUILDER OR OWNER DATE PERMIT ISSUED: l DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No c "�'v-1. ram/ �- 3�' � �� � 3� �$ oft}- ��% 7NO.OFBEDROOMS ��B�. STABLE �-. ie SEWAGE /,1 ASSESS R'S MAP &LOTOFS. 60` ' NAME&PHONE NO.NK CAPACITY I FACILrrY: (type) ,[�1 �3 (size)U BUILDER OR OWNER PERMIT DATE: 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) n - Feet Furnished by 9 O49�� 1l�/7 i1J7/�/'7 0 B NOV-19-2013 10:53 FROM: TO:15007906304 P.2 ti Massachusetts Department of Environmental Protection 1100186643 � Bureau of Waste Prevention—Air Quality vocal Number 1 Project Revision Notification LFor Asbestos Notification ANF-001 and AQ 06 Important: A FacilityLocation When filling out A. forms on the MARY ENCUSH computer,uee only the tab key 1.Neme of Facility I*move your "Ill MAIN ST t cursor-do not 2.Street Address use the return MA key. """'"h� J -KI 3.City 4.State 5-ZipCode 6087754999 0.Telephone Number INSTRucTIONS B. Project Cancelled 1. ThIS form IS only available for Check here if this project islwas cancelled, onllne filing of project date revisions, 2. Enter project decal number. C. Project Dates validate that the 10/ M013 10116/2013 iho project location is cormet 1.Ori anal Start Ste(mm/ddV=) fort"entered 11/18/2013 11 1/1 91201 3 decal. 3.Latest Devised Stert Data(mm/ddlyyyy) 4.Latest Revised End Date(mrn/ddlyyyy) 4. renter your new project dates. 5. Certify your ruilification. D. Revised Project Dates Submit date changes. 11/20/2013 11/21/9013 1.Revised Start Date(mm/ddfyyyy) 2,Revised End Date Date(mm/dd/yyyy) E. Other Project Revisions F. Revision Histo EDEP: 1QM112013 06:36:21 PM EDEP. 10/18/$013 03:54:29 PM � f i , i anf06pdrn.doc•rev.2/6104 4 i NOU-19-2013 10:53 FROM: TO:15097906304 P.3 commonwealth of Massachusetts - 18 100 6643 � i �. Asbestos Notification Form ANF-001 Uacr'I Number Important: A. Asbestos Abatement Description When filling out forms on the 1. a, Is this facility fee.exempt-city. town, district, municipal housing authority,Owner-occupied compuf®r,use only the tab key residence of four units Or less? ✓ Yes [J NO to move your cursor-do not b. provide blanket decal number if applicable,, Blanket Decal Number use the return key. 2. Facility Location: olMARY ENGUSH 481 MAIN ST s, me Facili b tre dtl s BARNSTABLE MA 02654 L;508)775.4999 c.CityITown d.State e,Zip Code .Telephone Numbee 3. Worksite Location; INSTRUCTIONS ^�..—....��� 1.All aeotlonsofthls SAME form must be a.Building Nama/Ruiiding Location b.Building# C Wing d.Floor e.Room completed in order to can,ply with 4. Is the falcifity occupied? 0 Yes ❑No DER notification requirements of 390 CMR 7.15 5 Asbestos Contractor: and Ilia Dlvislari qIR SAFE INC 61 ENDICOTT STREET of Occupational Satety(DOS) b.Address a.Name notification OD 02062 7817623390 �ORWO requirements of 463 d,—ZiD cqd@ a.Telephone Number CNIR 6.12 c.ci /Town AC000464 J g. Contract Type: Written Verbal DOS icense Num er aci I on act arson I.Contact Person's Tale JAIME E AMAYA _ AS060847 a. Nan+d- i E erviso_dForsman F Su ervisor/poreman D4S Cdrtific8tlon Number SAM COHEN AM060787 7. a.Name of Pro art Monitor b.Pro act monitor DOS Certification Number ENVIROTEST LABS IAA000128 8, -W.-Name of Asbasto�Anal lca'I Lab sbe- An ical D CerC' do mb r 10/15/2013 10/16/2013 d e.Pr oct start Date mmJdd�yytr b.End 08te mmJddl 0 7AM-GPM ry a. oi hour3 d.-Work ours sit-Sun. 10. a. VWhat type of project is this? r 11. e. Check abatement procedures: o Glove bag Encapsulation to Enclosure Disposal only a Cleanup C3 Other, specify: r- --.- — 0 Full containment b.Describe 12. Is the job being conducted; 2) Indoors? ❑Outdoors? any f� Op1 ap,doa-10102 Asbestos Notification Form•Page 1 of 3■ NOV-19-2013 10:53 FROM: TO:15oe7906304 PA commonwealth of Massachusetts �oa�gseas J i LlAsbestos Notification Form ANF-001 psaslNumbar 13. Facility Description (coat.) 5. a.Name of General Contractor � b.Address d�. e.Telc hone Number i�aa code and extension C,City/Town(Town f.Contractors Worker's Comp.insurer Policy Number h.F..z .©ate mmlddl YY 6. What is the size of this facility? a.Squaro Fact b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): AIRSAFE o.Name of_Trans04rter b.Address Note'Transfer Stations must comply with the c.City/Town d.Zip Cod® e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste Material from MmovaVtemporary site to final disposal site: Regulations 310 CMR 19.000 Ira_NNorng of Transporter b.Ad ressi ' c.Ci gown tv d,Zip e.Telephone Number a.Refuse Iansfer$tadon and owner II��b AddrAse c.C' awn dd.Zio Code o.Telephone Number 4. 1MIN9RVA ENTERPRISES a.Final DIS osal She Location Name b.Final pis osol Sito Loca6an t�nrnpr's Name 9000 MINERVA ROAD WAYNESBURG Final 03815 ArldrArr d.Cit !Town OH a4688 e.State f.Zip Code g.Telephone Number M Q D. Certification The undersigned hereby states,under the �F WAL$H o penalties of perjury,that he/she has read the _Narnp, b.Authorized Signature e Commonwealth of Massachusetts regulations VP for the Removal,Containment or c-P-ositionfr tie d. to m 1 dlvyv Encapsulation of Asbestos,453 CMR 6.00 and i(i61)762-3390 _ AS 310 CMR 7,15,and.that the information a.Tole hone Number f,R2presentinq Contained in this notification is true and correct to the best of his/her knowledge and belief. 161 ENDICOTT NORWOOD� 0201B2 h.CifyFTown i Zip Code 2 Q anfOD 1 ap doc• 10102 Asbestos Notification Form page 3 of 3 r V-19-2013 10:53 FROM: TO:15oe7906304 P.5 Commonwealth of Massachusetts I 100106;,* Asbestos Notification Form ANF-001 Decal Number A. Asbestos Abatement Description (cent.) 13, Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or -encapsulated: 19 1 170 a.'rotal pipes or ducts flinear o s o er su aces square c.Boiler,breaching,duct,tank 70 d.Insulating cement surface coatings Lin.ft ft Lin,`_'•'f, e.Corrugated or layered paper 18 f.TroweUSprayer coatings pipe insulation Lin,ft, ft. Lint � ft g.Spray-on fireproofing h.Transite board,wall board un,'�'"�"'� i,Cloths,woven fabrics ft"� i-Other,please specify: .-Lin-ft J tt k.Thermal,solid core pipe insulation Lin i.Specify 14. Describe the decontamination system(s)to be use 3 CMAMBER DECON 15. Describe the containerization/disposal methods to comply with 310 CMR 7,16 and 453 CMF7 8,14(2) ): 6 MIL POLY BAGS 16. For Emergency Asbestos Operation6,the DEP and DOS officials who evaluated the emergency: c-0816(nvWdd Y1Y o Authorization d.Dep Waiver e,Name of DOS Official a e I N g.Date y)of AuMorilation h.DOS Waived! i 0 17. Do prevailing wage writes as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? Yes No B. Facility Description o 1. Current or prior use of facility: RESIDENTIAL a 2. Is the facility owner-occupied residential anth 4 units or less? 1Z Yes C3 No SAM 3. r; a.Facility Owner fVarnO b.gddre6g o c d,Z Code e,TelephbKii Number area me an extension 4 j a Nernix o acili Owners On-Site Manager b.On.$hte Mana er Add me Z C.Chtyrown d.Zip Code e.Telerohormb Number(area code and extension) enf001ap.doc 10/02 Asbestos Notification Form-Pa a 2'Of 3 �i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ``' 481 MAIN ST Property Address INC ENGLISH Owner Owner's Name information is �r required for CENTERVILLE MA 02632 9-1-16 F•* every page. Citylrown State Zip Code Date of Inspection W 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 A. General Information � �� ? �j' forms on the 1.5 computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name VQ P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-1-16 In ito�es 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT TIME OF INSPECTION THE SYSTEM MET ALL PASSING REQUIREMENTS. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. THIS REPORT DOES NOT GUARANTEE BEDROOM COUNT OR DESIGN FLOW. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. City/Town 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-3/13 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 4 M , 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every 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 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 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 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 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. Cityrrown 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): 7per Number of bedrooms(actual): 10 per owner permit DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owners Name information is required for CENTERVILLE MA 02632 9-1-16 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO PERMIT SYSTEM CONSISTS OF A 2500 GALLON SEPTIC TANK D-BOX AND 3 6X8 PITS WITH 2 FT OF STONE Number of current residents: UNKNOWN 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: 14---------545 15--------397GPD SYSTEM IS NOT DESIGNED FOR USE WITH GARBAGE DISPOSAL Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENTLY 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•3/13 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 ,•°' 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): THERE IS WAS A PLAN AT THE BOARD OF HEALTH THAT SHOWS A PROPOSED GREAS TRAP BUT THERE WAS NOT ONE FOUND AND THERE WER NO OTHER DOCUMENTS SHOWING ONE. General Information Pumping Records: Source of information: 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): toms•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 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1989 PER PERMIT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 1 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: 2500 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. Citylrown 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 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 were dimensions determined? 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 LOOKED LIKE IT WAS RECENTLY PUMPED THE COVERS HAD BEEN DUG UP RECENTLY 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX LOOKED FINE AT TIME OF INSPECTION RECOMMEND INSTALLING SPEED LEVELS TO EVEN OUT FLOW, ONE PIT WAS RECIEVING MOST OF THE FLOW. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rt d °M 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ACCORDING TO PERMIT THERE ARE 3 6X8 PITS WITH 2 FT OF STONE. ALL THREE WERE VIEWED 2 WERE OPENED AND 1 WAS VIEWED BY CAMERA 2 WERE EMPTY AND THE ONE FUTHEST DOWN THE PROPERTY WAS FULL. Cesspools (cesspool must be pumped as part of ins pection) (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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every 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-3/13 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 wM 't 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every 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 t5ins•3/13 Title 5 Official Inspection Forth: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 �< 481 MAIN ST Property Address ENGLISH Owner Owner's Name information is required for CENTERVILLE MA 02632 9-1-16 every page. Citylrown 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: NO GW IN TEST PITS OFF PLANfeet 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: ATTACHED DESIGN PLAN BY ALL CAPE ENGINEERING Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 '< 481 MAIN ST Property Address ENGLISH Owner Owners Name information is required for CENTERVILLE MA 02632 9-1-16 every 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 SOWN OF BARNSTABLE :CA_iIC�iV SEWAGE# N,riLLAGE ASSESS R'S MAP &LOT6FS—C&� 2NSP&cMRS NAME&PHONE NO. e—e SEPTIC TANK CAPACITY FACILITY: 3 (size) D� LEACHING FAC (type) � � all NO.OF BEDROOMS �- U BUILDER OR OWNER 6k� zx� 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_Z91/l7 ?V O Ju �3 50 30 y3'ta 4 LP f 10-02-1997 12:53PM CENT OST FIREDEPT 5087902385 P.03 . ..KaX%c.ut'r w,.... w .vUca& a 11 C uC�/gl U11C31L Fire Department retains original application and issues duplicate as Permit.oev AQ�� QQC i � GrE�Gr�`iG�2 r7� /ZG�6P�b c---� r� ��•---� �e%►,G��'me�z�'��irxe V r��icea— ;/�aax�a�C�ri�►� �x�rtreztia�,�, +`�`;,�v� �-c C APPLICATION and PERMIT Fee: 1(,_no for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: , 3 Tank Owner Name(please print) Charter ank X JgrfaAlre BpYy )orp•rmrcl Address 481 Main Street Centerville Smoot city SF8149 DD Lnviro—Safe Corp. Enviro—Safe Corp. "CompanyName 7Co.orvidualptelrtnt Address P.O. Box 304, Sagamore Beach, MA Address Pant Pnn! SignatureI plyi f it) Signature(if applying for perm it) IFCI Certified Other. FCI Certified 2 LSP it Other Tank Location _ The Tnn at Fern Er LqL_ Sroot Adorq= �y Tank Capacity(gallons) 7 Substance Last Stored_ Tank Dimensions(diameter x length) Remarks: ri 7mrorting waste Enviro—Safe Corp State Lic.# MA-3 9 us waste mandes:I E.P.A. # Approved tank disposal yard _Turner Salvaee Tank yard# 002 Type of inert gas Tank yard address _ Lynn, MA lot City or Town Centerville 01920 FDID# Permit# I Date of issue October lj Date of expiration October 15, 1997 Dig safe approval number. 973907255 Dig Safe Toll Frees Tel. Number-800-322-4844 Signature/Title of Officer granting permit ` . After removal(s)send Form FP-290R signed by Local Fire Dept to UST Regulatory Compliance Unit,One Ashburton Place. Room 1310, Boston,MA 02108.161'8. /IJ g FP 292(revised 9/961 ( ! 7 �� 10-02-1997 12:53PM CENT DST FIREDEPT 5087902385 P.04 . ...una.arN�wua.w. w n/Vol rue LmlimunenL - Fire Department retains original application and issues duplicate as Permit. Q, Q Q4`Ulf �pdr�zni,a�ncr�ea�� fz�Ci�� APPLICATION and PERMIT Fee:--jn`rnnr for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR,,9.00, application is hereby made by: Tank Owner Name (please pdr1) Charter Bank X gnaruro +rapaft tarpennn Address 481 Main Street Centerville Street chy state rip Enviro-Safe Corp. Enviro-Safe Corp. Company Name Pant Co.or Individual P.O. Box 304, Sagamore Beach, MA Address Address Pmt r�nl Signature DCOIng fcr 't) Signature(if applying for permit) IFCI Certified Other IFCI Certified Z >_SP# Other Tank , , . Tank Location 481 Main Str Cenrerville - -The Inn at Fern Brook Steel Address Tank Capacit (gallons) 500 y(9 ) Substance last Stored � � Tank Dimensions(diameter x length) Remarks: rMirmmtrmansporting waste Enviro-Safe Corp State Lic. #___ MA-3 .9 Hazardous waste manifes—, E.P.A. # Approved tank disposal vard Turner Salvage Tank yard # 002 Type of inert gas Tank yard address Lynn. MA City or Town Centerville 01920 FDID# Permit# Date of issue October 1; Date of expiration October 15, 1997 Dig safe approval number, 973907255 Dig Safe Toll Free Tel. Number-800-322-4844 Signature/Title of Officer granting permit After removal(s)send Form FP-290R signed by Local Fire Dept.to UST Regulatory Compliance Unit, One Ashburton Place. Room 1310, Boston, MA C2,08-1618. FP•292(revised 9196) 1 011-�C1 ! V v TOTAL P.04 12 s�' plop F4b <F`6 �� W BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 h°FOT,SB(F 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` 9 PART A QQ CERTIFICATION Property Address: 1 /g/li/ij A A-Y., Date of Inspection: 9h 7AXi I spector's Name P"er's Name and Address(7 093 CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal Stems. The System: Passes Conditionally Passes Needs Further aluation By the Local Aproving Authority Fails Inspector's Signature: Date: 9,/ 9"I The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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. INSPECTION SUMNLARY• A)SYST PASSES: I have not found any information which indicates that the system violates any of the failure. criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,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,cracked, structurally unsound,shows.substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by.The Board of Health. Sewage backkup 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): - 1 - 1'I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .. CERTIFICATION (continued) - ,•''i r' Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced 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 - •- 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 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and 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 is with a Zone I.of a public water supply well. " The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined i in 310 CIviR 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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-clog- ged 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 -2- r 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 I 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. 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: 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 I1 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . .. . . _ .. . CHECKLIST �/ Check V the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast 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. l/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 site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, Xpth of sludge,depth of scum. (/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 1/ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow: gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings,if available: Last Date of Occupancy: COMMERCIAL/INDUSTRIAL: Type of Establishment:�i /x� Design Flow: qQ0 gallons/day Grease Trap Present: (yes or no) X-)U Industrial Waste Holding Tank Present: A-)C) Non-Sanitary Waste Discharged To The Title V System: O Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) /jU Last Date of Occupancy: GENE L INFORMATION PUMPING RECORDS and source of information: . "9w System Pumped as part of inspection: ,w If ye ,volume pumped: gallons Reason for pumping: TYP"F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APP ROXIMATE A E of all components,date installed(if known)and source of, information: Sew a odors detected when arriving at the site: 4.20 -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORM(,AQT�IO�N/ (continued) - SEPTIC TANK: /�C` - Depth below grade: Material of Construction: concrete metal FRP_Other (explain) Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments::(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid leyel in relation outlet invert,structural integrity,evidence o leakage,etc) is 0 0— �. i GREASE TRAP: L)b Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:—concrete—metal FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of 51ann"and float switches;etc.) ' DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note iflevel and distribution is equal, evidence of solids carryover,evide a of leakage into or out of box,etc.)I&/Q� (»JU i L �Xn PUMP CHAMBER:/Uy Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): v (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number:Leaching chambers, number: Leaching gaileries,number: Leaching trenches, number, length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil, signs of hydraul' failu level o ponding,condition of vegetation, etc.) �X- /��,,/ 4/41U CESSPOOLS: A)O 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:Ab Materials of construction: Dimensions; Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. n _.. _ 3 00 3cp �' 7 DEPTH TO GROUNDWATER: Depth to groundwater: Z- Feet Meth of Determination or Appro 'matio /1�,X/<tA¢fz� i��� G� c' �� r ev -7 TOWN OF BARNSTABLE SEWAGE # LOCATION VILLAGE_lf �' �°^ ���LL a ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:{type) NO. OF BEDROOMS--?—PRIVATE WELL OR PUBLIC WATER � ? BUILDER OR OWNER DATE PERMIT ISSUED: l DATE COMPLIANCE ISSUED: No VARIANCE GRANTED: Yes - -- 0 3� • � : -1._�-_4_. ;- .-;- �^. _4_-r..�-- �`--}' _---�- - - -t--�,'- --- 444 -T14 1- r i 1. f + t - - /�•:�� �` _ 1 t _F7 a. I _.� _.k-} I'r�. • � ! ; {?. I .;. � :. !__ _. ._�-'t- _-�- _. ._.. _... ._ -- '- _� - - - - _.�_'_:---r--•-..I -:--�'± -'T 1-t -*-,- �-�. +i i.... 1 � j-}'--� '-t 'f.__Ij__ I �_.t ..i _ . I ! 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TREE ' O "II N •; 18.0' -17:4''% 4. 4' ASSESSORS MAP 208 44. - - w a1ANHOLE MEDGES `', cfrl' I PPRCH _:16 - - _ - SEPTIC - - - - - - - - - - - — — - '�-� ___ _ _ ___ _ _ __ _ _ _ __ _-- -1-7 =_--- b 1 -_-- --_-THE' INN AT FERNBROOK -_--__?\5 . � � 1 1 I�RIVE'WAYS !l �—� o= - - - - - - - - - - -�- - - - - - - - � � BLACK ,A 3 - _ _------ -------------_#481___- ---__-_----� OAK • 'r —11. T'- - - - =� _co-`Ssr- BLACK cT_ 101. 4 -s - - - - - MR - .- - - r BRICK RET- - - - - - - - h- -� 9�� _ WALNUT WALL b 0 � �� - - - Q PR4�RO.SED 9 O' — - - - - - r ADd ON GtcE1T ME a ool "E CEDAR' - �. K9TSURA IV80 z TES _ 60 N >._ -#LUJYDRY - l` Yt' P NT - LT e.o b E ASPHALT PARKING BLACK h TREE GARDE:'V Cj. o_ GRA VEL OAK - WALKS AREA / CONC •� ARBOR MANHOLE . 14 '� DECK C B. (IT I APPEARS TO BE NONFUNCTIONING WELL) 2Q5 \ GJ� g SITE PLAN T A 6'' (FOR SITE PLAN REVIEW) OF LAND LOCA TED IN BARNSTABLE,, MA. (CENTERVILLE) LOT 30 ' �' PREPARED. FOR fa Yk► C� CHARLES R. & SANDRA HARMON MA Y ANN WUTHRICH CTF 141239 ATE; APRIL 8, 1998 -_ - t EV v APRIL 17,' 1998. I .CERTIFY THAT. THIS SURVEY AND PLAN WERE MADE - JANUARY 8, 2002 IN ACCORDANCE WITH THE PROCEDURAL AND TECHNICAL STANDARDS FOR THE PRACTICE OF LAND SURVEYING IN �JV�vv h COMMONWEALTH OF AMSSACHUSETTS. PA UL A. MERITHEW, P.L.S. DA S GRAPHIC SCALE �� 20 0 10 . 20 40 90 �� I YANKEE SURVEY CONSULTANTS � . .UNIT 1, 40 INDUSTRY ROAD Tom•- P. O. BOX 265 _ IN MARSTONS MILLS, MASS. 0,2648 1 inch FEET f t. TEL- 428-0055 FAX 420-5553 k4,i _ ��, C.ia1 JOB 51549A DPG - ✓wU