HomeMy WebLinkAbout4424 FALMOUTH ROAD/RTE 28 - Health �4424 M ; `IJTft,RO.ADP'
Cotuit= �J
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UPC 12834
No.2® 153LW ,
HASTINGS, MW
�� 99
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftphLation for Mispo8al 6pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's NN e, ef sand Tel,,j, . (
Assessor's Map/Parcel �" U
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms /" Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) IV 0e gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
.41
&N ture of Repairs or Alt rations(Answer when applicable) '
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental a an not to place system in operation until a Certificate of
Compliance has been issued by this Board of Health.
t
Signe Date
Application Approved by 6 Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued `'� "C
C ._, .,.. ._, ., -� h,_-� sue..:,_ ..�,}.,-.':-t♦ x - ., .. ..{1 •�t '"� a r .-.t Hg,�_.:
.s
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No. PA r � �� T } Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplication for Misposal *pstrm (Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 4 El Complete System ❑Individual Components
Location Address or Lot No.Gl"�d Ow er s/Name, ddre�s,and Tel.N .
Assessor's Map/Parcel C7-;P"7
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building: A
Dwelling No.of Bedrooms /" Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures on \
Design Flow(min.required) gpd Design flow provided a gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank type of S.A.S.
Description of Soil �}
�N (:�
�ture of Repairs or Al rations(Answer when applicable) G� "Oh
Date last inspected: ,° E
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in rt't
C . accordance with the provisions of Title 5 of the Environmental iode an not to place system in operation until a Certificate of
kCompliance has been issued by this Board of Health. s
Signed. Date
Application Approved by t - Date _ y
Application Disapproved by Date
for the following reasons r
r. Permit No. b r Date Issued .4'5
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Aban`do/need`( )�by I
�y has been constructed.in acco dance
with the provisions of Title 5 and the for Disposal System Construction Permit No!��,�5( dated _ -2- �rJ
Installer Designer ;
#bedrooms Approved design flow gpd
The issuance of this permit shal not be construed as a guarantee that the system` ill functio ,as e i e .
Date. A Inspector n -...._ -
r
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 0pstpm Construction Permit
Permission is hereby granted to Construct( ) epair( ) Upgrade( j Abandon
System located at � Y' g,4 (5 C
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
\ Title 5 and the following local provisions or special conditions.
Provided:Constru ion rp s pcompl-fie +within three years of the date of this permi
Date Approved by
`�J
r
TOWN(�OF BARNST LE
LOCAVIION qya 1 RT a� PA)MOA ftT SEWAGE #
r1I,LAGE C O th ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I oyd G�easc /OUb Sept-L
FACILITY: �T CoX6 - (size) S%p
LEACHING FACIL (type) P
NO.OF BEDROOMS II Z&A6r'%l
BUII.DER OR OWNER CfJTv+ ��� + T c.'�(k
PERMrTbATE: COMPLIANCE DATE:
Separation Distance Between the: VJ11_ktc
1
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 wetlands exist
within 300 feet of leaching facility) Feet
Furnished by :r;qq«rt,-, 3 Fob o aG oc�
I/ a
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A sp6l+Li
4
ao a
a S9 sronc PArtl'r
60 a
3 y
i
l _
OWN OF BARNSTABL
LOCATION ���l - � Z� �� �' ��SEWAGE#.
VILLAGE fu/ 1-4- ASSESSOR'S MAP& LOT OZW 4921e�,
INSTALLER'S NAME&PHONE NO. T xpz� i`
GrMsa
�
SEPTIC TANK CAPACITY eV 6 L i A-V /,000 L
LEACHING FACILrrY: (type) (size) Ale)
NO.OF BEDROOMS 1
BUILDER OR OWNER 60/y,
PERMrrDATE: 1-24 —�?h 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 Feet
within 300 feet of leaching facility)
Furnished by
YYX 7
e�l'bo to
8a"S-9,
193-7y Q L
e
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TOWN OF BARNSTABLEQ �
LOCATION U SEWAGE#
�TLLAGE_ 7`(s�r� ASSESSO 'S MAP &LOT �a� �
TL is o�R7�s' �/
NAME&PHONE NO. O ys
SEPTIC TANK CAPACITY 4100
LEACHING FACILITY: (type) Z (size) 1600 670
NO.OF BEDROOMS
BUILDER kR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
i
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 leachin,ffacili Feet
Furnished by
' j .
I
TOWN OF BARNSTABLE
LOCATION CTXJv�I SEWAGE # .0
VILLAGE ASSESSOR'S MAP & LOT 2-0
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY \ Q O U
LEACHING FACILITY:(type) (size) `4'v(0-
NO. OF BEDROOMS PRIVATE WELL OrUBLIC WATE '
BUILDER OR OWNER c r--CArC(?
DATE PERMIT ISSUED: co -C6 (Q
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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1
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508428-8926 FAX: 508428-9399 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
47
Property Address: a p a," 'off
Date of Inspection: . cV -qe, Inspector's Name: >
Oar's Name and Address: CJ
C1 1�lfi o�� /721119
_CERTIFICATION STA M .NT•
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:
y Passes
Conditionally Passes
Needs Further valuation By the Local Aproving Authority
Fails I /
Inspector's Signature: Date: �A7!Q C
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.
INSPECTIO/N MMARY•
A)SYSTF PASSES:
y 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
P c tank as approved g P ed b The Board of Health
PP Y
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
�a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM =F
PART A
CERTIFICATION(continued)
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
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.
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-
x.'
a
/
.r< SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
t 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 5.0 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 lI 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 if 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.
✓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,
depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
. R .. .�
:,tra
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
i
LZThe 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
RF.SIDENTL
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:
COM1 /
•
Type of Establishment � %/
Design Flow: gallons/day Grease Trap Present:.(yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informati
System Pumped as part of inspection:_ If yes,volume pumped: gallons
Reason for pumping:
TYPE 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):
APPROXIMATE AGE of all components,date installed(if known)and source of information:
` Sewage odors detected when arriving at the site:
i -4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grader! Material of Construction:�oncrete metal FRP Other
(explain)
Dimisions: X 8 Y5" Sludge Depth: 43' Scum.Thickness:(0
Distance from top of sludge to bottom of outlet tee or baffle: 3$"
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
level in relation to outlet invert,structural integrity,evidence leakage,etc'�,� 'S � /wo
_ S
fe
GREASE TRAP:
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 .)inlet tee,condition of alarm and float switches etc.
.)
DISTRIBUTION BOX:_/
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids c over,evidence of leakage into
or out of box,etc.) �, '
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5- i
3 .F
1p
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):
(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 galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation,
etc.)ZI —
' ,
CESSPOOLS:
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:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
-6-
5A
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references landmark
Locate all wells within 100 Feet. s or benchmarks.
v
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DEPTH TO GROUNDWATER:
Depth to groundwater:
Feet
Method ofDetermination or Approximation: zli J,
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_ _7_
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Town of Barnstable
- �F1HE raY
o Regulatory Services
STAB Thomas F. Geiler,Director
BAM9� 69. •�� Public Health Division
ACED�AA'�A
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
November 27, 2006
Mr Leonard Coronella
c/o Michael J. Gill, Esq
29 Bassett Lane
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system owned by you located at 4424 Falmouth Road, Cotuit,MA was last
inspected October 26th 2006 by, James M. Ford, a certified septic inspector for the
State of Massachusetts.
The inspection of your septic system showed that your system"Needs Further
Evaluation"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the
following:
Septic tank and leach pit are under a stone parking lot and is H-10 loading.
As per telephone conversation: If stone is removed and replaced with grass or
mulch AND a fence is used to close off this area; the requirements should be met for
the Town of Barnstable Septic Regulations.
You have 2 years from the date of the system failure to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable
Health Department.
BARNSTABLE HEALTH DEPARTMENT
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Cc: Michael J. Gill, Esq
r1
2G IF-
Nov , 15 . 2006 10 : 25AM GILL DEVINE & WHITE PC No , 5417 P . 1
GILL, DEVINE & WHITE P.C.
Attorneys and Counselors al Law
29 Bassett Lane
Hyannis, Massachusetts 02601
Tolephone:508.957,6015
Facsimile: 508.957.6033
Michael J.Gill,Esq.
rnichae1@gdw1dw.com
FACSIMILE COVER PAGE
To: Judith Flynn,Board of Health From: Michael Gill
Michaels Edwlaw.com
Fax: 508-790-6304
Date: November 15,2006
Re: Septic Report
Pages: �,� (including cover)
Judith:
Nice speaking with you today. Thank you for your assistance, I've attached the report which
we received yesterday. We are looking for further guidance from your office as to how to
proceed. The closing on this property was scheduled for today, but it doesn't look like that is
going to happen.
Before the systeln is deemed a"failed" system, I'd ask one question and that is that if there is
stone parking lot (under which is the septic)and an asphalt area(no septic there), would it be
acceptable to just convert the stone parking lot into a non-parking area, i.e., remove the stone
and put in mulch or grass?
Should you have any questions or comments, please do not hesitate to call or e-mail me.
Thanks again, Michael
0
NOTICE: The documents accompanying this facsimile transmission contain certain confidential or privileged information from the law
firm of Gill,Devine&White P.C.This information is intended to be for the use of the individual or entity named on this cover sheet. If you
are not the intended recipient,be aware that any disclosure, copying,distribution oi,use of The contents of this facsimile transmission is
prohibited.If you have any problems receiriag,please call the person sending immediately.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit. MA.02635
Owner's Name: Leonard Coronella
Owner's Address: D OD
Date of Inspection: October 26, 2606
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
E
E
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the informations ported:
below is true, accurate and complete as of the time of the inspection. The inspection was performeJ1 based o y
training and experience in the proper function and maintenance of on site sewage disposal systems 1 I am a.D.EP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sygpm: '
Passes
Conditionally Passes --
✓ Ne s Further Evaluation by the Local Approving Aut ority t_J II-
Fai s cn rn
Inspector's Signature: Date: November.]. 2006
The system inspector shall sub it 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
DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
NOTE:Septic tank and leach pit are under a stone parking lot and are H-10 loading. Needs further evaluation.
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit, M.4
Owner: Leonard Coronella
Date of Inspection: October 26, 2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined.(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:.
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
f
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit, MA
Owner: Leonard Coronella
Date of Inspection: October 26, 2006
C. Further Evaluation is Required by the Board of Health:
✓ Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
'1-3. Other:
The tank and leach nit are under a stone narking lot and are H-10 loading. Further evaluation is needed
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit, MA
Owner: Leonard Coronella
Date of Inspection: October 26. 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit, km .
Owner: Leonard Coronella
Date of Inspection: October 26, 2006
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:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
.5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:. 4424 Falmouth Road(Rte. 28)
Cotuit, MA
Owner: Leonard Coronella
Date of Inspection: October 26, 2006
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: I 10 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use(yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: Converted bakery
Design flow(based on 310 CMR 15.203): apd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): Yes
Industrial waste holding tank present(yes or no) No
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available: Unavailable
Last date of occupancy/use: Unknown
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 2 years ago-per owner
Was system pumped as part of the inspection(yes or no): 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) .
Tight Tank Attach a copy of the DEP approval
` . Other(describe):
f Approximate age of all components,date installed(if known)and source of information:
Installed in 1996-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
r
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION(continued)
Property Address: 4424 Fahnouth Road(Rte. 28)
Cotuit, MA
Owner: Leonard Coronella
Date of Inspection: October 26. 2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Continents (on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 18"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain).
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal. (H-10)
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: I
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: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. There did not appear to be anv signs ofleakage The tank is H 10 and in a stone area o the parking
lot. The inlet cover is 8"below grade and anew cover is needed Further evaluation is required
GREASE TRAP: ✓ (locate on site plan)
Depth below grade- 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions: 1000 gal. (H-20)-under asphalt
Scum thickness: IV
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: Unknown
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
The steel cover was to grade. Tees were present. There did not appear to be any signs of leakage Recommend gumpi�
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit. MA
Owner: Leonard Coronella
Date of Inspection: October 26, 2006
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day.
Alarm present(yes or no): I
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments.(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4424 Falnsouth Road(Rte. 28)
Cotuit, MA
Owner: Leonard Coronella
Date of Inspection: October 26, 2006
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 6'x 6'(1000 ga1J H-10
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.):
The nit was dry. The scum line was 4"un from the bottom The cover was 12"below jzrade. The pit was H 10 and under a stone
parking lot. Further evaluation is needed
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Commments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Coirunents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
•' Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit, MA
Owner: Leonard Coronella .
Date of Inspection: October 26, 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4424 Falmouth Road(Rte. 28)
Cotuit, MA
Owner: Leonard Coronella
Date of Inspection: October 26, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 35+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within.150 feet of SAS)
✓ Checked with local Board of Health-explain: Topogaphic and water contours map
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the maps were showing agproximatelV 35'+1-to Around water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and further evaluation is required as of the date of inspection. This report is not a warranty or guarantee that
the system will function properly in the future. There have been no warranties or guarantees; either expressed, written
or implied, relating to the septic system, the inspection, this report and/or an components o the septic system which have`
Y p .r p Y
not been located and inspected
11
60) y POAe,
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-711-9399 508428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: `l a? bC
Date of Inspection: " d - Inspector's Name: t -L ,
is Name and Address: -,�-• - p �
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the informs-.
don 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 systems. The System:
�/ Passes
Conditionally Passes
Needs Further§valuation By the Local Aproving Authority
Fails
Inspector's Signature: Date: a 7/19
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 S iMMARV•
A)SYS 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 _
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
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 AXANNER 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. Y
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 of ammonia en and nitrate nitrogen is equal to or less
- presence nitrogen
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
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.
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 G"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-
1
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 II 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 if the following have been done:
_ePumping 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.
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.
he 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,
depth of sludge,depth of scum.
*"'The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
L i pe facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE'SEWAGE DISPOSAL SYSTEM-INSPECTIOMFORM
PART C
SYSTEM INFORMATION ,
FLOW CONDITIONS
RESIDENTIAL* V/0
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:
COMMERC
Type of Establishment:ct
Design Flow: ' gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
,Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of inforinati n/
System Pumped as part of inspection: If yes,volume gallons.
Reason for pumping:
TYP5,W 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):
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site:
-4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade:'4 '2 , Material of Construction:_zconcrete metal FRP—Other
(explain)
Dimisions:_$•, ,Y6,Y5' Sludge Depth: *�3'1 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
level in relation to outlet invert,structural integrity,evidence of leakage,etc. S 4z, /b,pp /j
S
1 Wd �i
GREASE TRAP:
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 battle:
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 alarm and float switches,etc.)
DISTRIBUTION BOX:_/
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carjrvover,evidence of leakage into
or out of box,etc.)
A40i' S
PUMP CHAMBER.-A6
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
is
• i
*:. ,,`
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):_
(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 galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
- Comments: (note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation,
etc. -
S-0
CESSPOOLS:
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:
-264
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6
I
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. E
o
-lqb
DEPTH TO GROUNDWATER:
Depth to groundwater: Z—Jr Feet
Method of Dete •nation or Approximation:
/ c.,
/J TOWN OF BARNSTAB
• .00A-TION ` - �` / SEWAGE# 9d'Z 3
VILLAGE ���u/,� ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. T 7�9ld��'
SEPTIC TANK CAPACITY GrL T�iy �,OdD Gay L
LEACHING FACILITY: (type) (size) ,cld
NO.OF BEDROOMS 1
BUILDER OR OWNER 601y,/T ��
PERMITDATE: 1-24 — 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 Feet
within 300 feet of leaching facility)
Furnished by
19V'43�
.83'bf
0 1�
60
TOWN OF BARNST LE
LOC,:TION qq;y FAIMOA SEWAGE # C'1(0- a3
VILLAGE CU v;{' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /a G(edSe, /OUb -Se 161L
LEACHING FACILITY: (type) PiT �oX6 (size)
NO.OF BEDROOMS
BUILDER OR OWNER C 07-0 6,t 1� -, ?^ AA6rY
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: � ` A r 5 -S CLIe4d-.,ytSc�"VO-r�1 QW
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 wetlands exist
within 300 feet of leaching facility) Feet
Furnished by rA- ge&r*M 3 F0XJ i 04 o�
Ei
1
cry,�1SG �$PI,QI}-
BA0 'IrA
coo
1-
Q
ao a6
S'font Park�„�
a 60L Sq a
31y �� 3p
r
TOWN OF BARNSTABLE
1_.00ATION 442 U SEWAGE#
VTLLAGEi // ASSESSO 'S MAP &LOT �a�G��
�S O�,gs rfD 9� i'°�NAME&PHONE NO. d YkP
SEPTIC TANK CAPACITY LSD aol. e,
LEACHING FACII.TTY: (type) zi �4 (size) 1600 GO
NO.OF BEDROOMS "/
BUELDER R OWNER J l7 / .t i i�� -7661�1 e
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
i
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 le chink�ff®cili 7 l Feet
Furnished by 1 ���
cp'' '
/FEE
No.
THE COMMONWEALTH OF MASSACHUSETTS
, MASSACHUSETTS
kypfirafivu for Pisposal ��$#em C�II�ts#rur#t`IIrt 1hruttit
Application is hereby made for a Permit to Construct( ) or Repair(P4 an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
VY� �§ ��lnwarlGt / .a� G��.; RA-t T- aC
aad /LTA >-F-
Instal Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
/WOst'-,r iK 7 G�nl s i- Cl✓C.T c a)i'�'1 C�7J.�i
-7tps L jA-W__"If 4UAb
444*/Ld-7_C13s t% (I,l_1 �VYL't—0"VT-
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder(b<
Other Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -,A-z b /4-- C 00 O �e.L C/-f -/o)
(�/L,�A�=-is- 'TU �C�sTi�l'G� cSf�L -S`1�'�-✓v1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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
Certificate of Compliance has bee ' sueg by thisr f Health.
Signed Date
Application Approved by Date -.1-U
Application Disapproved for the following reasons
Permit No. Cg ` a Date Issued —�U —
_ _
., No. �9�_ FEE
THE COMMONWEALTH OF MASSACHUSETTS.
L -, MASSACHUSETTS
" c kpyfirativn for Pisposal **stem (gortstrurttort 1hrutit
Application is hereby made for a Permit to Construct( )or Repair(p4 an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Instal] Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
,LSOiC7C"U F, Gt n1 ST. %�C�C t�/ c
—7CoS- L JA-jl_"-! Q�
r
Type of Building:
r Dwelling No. of Bedrooms ��'`� Garbage Grinder(�
16ther Type of Building CC^�A t&cl A-S No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
F- Plan Date Number of sheets Revision Date
Title
' Description of Soil
Nature of Repairs or Alterations�(Answer when applicable) A-0 lb A 000 56.L.
7-7W '7 U 770-E. C (.s i 7116� -S'&O-, Z L SY�c yr�
Date last inspected:
Agr"eement: �""`"""'
The undersigned agrees to ensure the construction,and maintenance of the afored'escribed on-site sewage disposal
i system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has bee sue by this Mrf Health.
Date Signed
Application Approved by Date d- Q_Li _ K 4—
Application Disapproved for the following reasons s
t7.
Permit No. 6 Date Issued - v G
THJE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS`
k
(gertiftrate of (gomplianre
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired/replaced on
' by _47.02-1 -VIL-07TI GG(,JJ7/ty C71W for ��1�r! /L►' ��
at ►41 iU ri �A-tT` �' Ti�GIBG�a� has been constructed in
accordance with the rovisions of Title 5 and the for Disposal System Construction Permit No. 2Z7 dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Q 3 - 9 7 Inspectori
THE COMMONWEALTH OF MASSACHUSETTS'
No. � � J / , MASSACHUSETTS FEE — -
Visposal Sgstem 0.1ozcstrurtion jermtt
Permission is hereby granted to -2'G/CT-GW 77
to construct( ) or repair(e,-/-)_an On-site Sewa a System located at VV_ y ���-
� —77;*Q/_Le C u i u r,1—
and as described in the above Application for Disposal System Construction Permit. 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 byT 1
FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON.MA
�.E7
f
._ TOWN OF BARNSTABLE
LOCATION a'F- CnvkT S WAGE #-2f(o
VILLAGE ebb 04 ASSESSOR'S MAP & LOT 2� 2r7
INSTALLER'S NAME & PHONE NO.
r
SEPTIC TANK CAPACITY \®O O . �+(� J
LEACHING FACILITY:(type) (size) '4 fsi
NO. OF BEDROOMS PRIVATE WELL'O BLIC WATE
BUILDER OR OWNER 6ri, %r
DATE PERMIT ISSUED: (�
DATE . COMPLIANCE ISSUED: � jcf Z5-r-j
VARIANCE GRANTED: Yes No 1C
I 0 00 sr�Pilc
ST
y/ .
r
t
`_3bR,N *'TEA.TH DEPT.
THE COMMONWEALTH OF MASSACHUSETTS
` A/ BOARD F HEALTH iv\ ��� Dq
` oI�..Y�....'..1..........o Fy ....:. ..1
� 1.. ............... �,0
Appliration for Disposal larks C1lanstxnr#iun Frrmi# �
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
• ..-..-.. .Lo....c. -•Address-- -•-••--•. .......... or
= No.
............. .y.a�. ��v� :........:..
--
Owner Address
.......
Installer
Address
Type of Building Size Lot............................Sq. feet
r-, Dwelling—No. of Bedrooms.._................................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ............................ No. of persons............................ Showers
a ( ) — Cafeteria ( )
04 Other fixtures --------•---------------- --------------
W Design Flow.. ..1 ._ _v.........................gallons per person per-day. Total daily fpw----- _._...............gallons.
WSeptic Tank Liquid capacity allons Length... _...... Width....Y. Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No... .............. Diameter... _ __. Depth below inlet...4: PZ....... Total leaching area..................sq. ft.
Z Other Distribution box ( �_ Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. 1...............minutes per inch Depth of Test Pit.................... Depth to ground water........................
I
G>~ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ........---------------------------
------------------------------ -------------------------
---------------
••••-...._.......---------------------
...•-
O Description of Soil................AL. ----.Ct.7.,0: a. �5' --•------------•-------•------------......--••-----
U
W
U Natur f Repairs or Alterations—Answer when applicable.......�.. VL
--- . ..._._i- _ ....�. . ...............
U -S'
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LITi LF, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complian b the an2q , e th.
Q
Sined._. ----• .----• ------ --•---•-•--•-•- ''-
/�1:4
aApplication Approved BY - .......((�
�l .a
--•••........... ...............• ate
Application Disapproved for the following reasons------------------•-------------------•---------------------------------...--------•••--••-•-•••................
--------------------•-•-•---.......------...---....--------------.....---------------..............-------•••--••---••--•••......-•---••.................. ............................................
Date
Permit No......
... ......... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH IVY Y�T Dq
'. -'1, .. --..-...oF..... .. � 1 '. ..1. ..................
Appi uttfion for, Disposal Workii T000irur#ioii Vrrutit
Application-iss=hereby made fora Permit to Construct ( ) or.:.Repair ( ) am,Individual Sewage Disposal
System at:
....:........_:L .. .....2.......... .. ....................:�.. ......-......... LJ C� ..
t' _ .. ......_.d..:._S. ..0.� ....._..._.
- Location-Address
--
t or Lot No.
,-ner —.
�.........3...._... ........ _
Installer _....,..
es
T e of Building Size
Ls
3'p g - ------�� Size Lot---:---:....................Sq. feet
►-, Dwelling—No. of Bedrooms........_................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other`—T e of Buildin
yp g ............................ No. of persons............................ Showers. Cafeteria ( )
d Other fixtures ........................................................... ^-� =
W Design Flow..___/...l,?_-_-...__� .gallons per person peryday. Total daily6fl�w.._...-1.2--�..�...................gallons.
WSeptic Tank Z Liquld capacity,___._-.___gallons Length._._.__.. Width.--_._-_. Diameter................ Depth................
x. Disposal Trench—No................. ... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage"Pit No �.......... ....�C..........
' r li...... Depth below inlet... _-._ ._... Total leaching area..................sq. ft.
�... Diameter /
Z Other Distribution box ( Z-)'-- Dosing tank.( )
Percolation Test Results Performed by.. --- -----------------•------------------••----....--- Date
Test Pit No. 1................minutes per inch Depth of Test Pit.....................Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
Da •---------------------------------------------------........................................................................................................
Description of Soil................. C"r_� ► .G.: .. :" �----------------------•--
U ----------- --------------•----. "*-••-------;-------------------------------•------------- --------------
•--------------------------
......
W
U Nature/of Repairs or'Alterafions# (Answer when applicable--------P:V.YlA n......cl�--�
-------C).k.I ..._.�.
^.. �;n-` ' `,t✓• f C57? . e=` ti`! --....----
Agreement:.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'ITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has-been rssued by Rthe oard of health.
i
e Signed-----
Application Approved By..--- �'� .....-•---• --_6. _.. .. C�..
at
Application Disapproved for the following reasons:................................................................................................................
.......................................................•-•------•••-------...----•--•------••--......---•---•----------•••--•-•--------•-•--•-------------- ••-----------•------............._...._.
Date
PermitNo........... .-- --- '��� --__._..' Issued-........................................... .....
Date
THE COMMONWEALTH OF MASSACHUSETTS Try
BOARD OF HEALTH
t' •. .. ....OF........!`j2. r: : ... .�r� ..........................
t Trrfif iratr of Tompliaurr
TH S-g--T._O, CERTIFY, That 11 e�hl`dividual Sewage Disposal System constructed or Repaired
by......;........: �. 'v-.:......... -`� -F,.Y~l� ( )
Installer
at.................-_....- �`� -�.. t C-`-... - C c3Tu� -------------•----•----------------•-------•--...........--_....
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.�' ...._ ...... dated ..�,��.�. .- ---------------------
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUAR�THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................ ....G..l.. ............................ Inspector Inspector.....---..........................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
"`� ........
O F F .( ..rh.c,...... -....................
Nsposal.-- :orko Toads:' n f amit
Permission is hereby granted.............
/"'-..
to Construct ( ) or Repair ( A_�an Iiylividual Sewage Disposal System
atNo. Cv� -------.._:..........�.. 1rt .---------------------•------------------------...............
Street
as shown on the application for Disposal Works Construction Permit �- �z, D<ated_._�F,t�Oi��-------------------
-----•. �C r-r, ------- ..................................
DATE. u„, �a
w,
-� THE COMMONWEALTH OFMASSACHUSETTSv�y�v� A'PRA9
BARNSTABLE,MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at has been constructed in acco dance
with the provisions of Title 5 and the for Disposal System Construction Permit Noz90 —z93 dated R .
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit sh4 not be onstrued as a guarantee that the system ill functio e
Date Inspector
i
COTUIT
ASSESSORS LOT 14
MELODY GAR
0��� 6
VELL'
DEED. 82681245 �` POND S
o LOCUS
i C.B./DISC(FND) �ti4
41 PLAN REF 350120, 273140 Q�
RES. ZONE: "RF"
FLOOD ZONE. "PC"
SETBACKS. 30-15-15 LOCUS MAP
STK(FND) ASSESSORS LOT 20
< SANTA CORONELLA
DEED: 35121114
ASSESSORS LOT 21
�o REGAN JASON
DEED: 80021142 BENCHMARK
GAS STA TION TOP OF TAGBOLT
WOODED AREA
ON HYDRANT
ELEV. � 100, O'(ASSUMED)
WOODS
N
W,.,._ _
GRASSY ��
moo' 1 I
f
`7
335
AREA
20 \ \ GAS 19'
\ D METER EL EC ti
ITE EVI�'W PLAN `�
�— dIETER
OF LAND IN \. .
GR.E'AS�'.�. .:
CO TUIT. A ASSESSORS LOT 19 �' GRA VEL - 1000 GAL <:
�`� 20"AMPLE
�PAUL BEA TTIE' O,z, IQ 3' '� � � W
PREPARED FOR:
DEED. 4290/208 0
l ti
� p
RAGE
�LEARD O SANTA CORONLLLA
PAR ING Ems sic
3
4 424 FALMO UTH ROAD Q SYSTEM '
COTUIT, MA. 02635 ,CV
TEL.• 428-2111 0
.ti
,
FEBRUARY 12, 1996 _ �`9N9A-'
LEGEND
0 H OF o
GRAPHIC SCALE
LAMP pA�sgcy Iq
20 0: 10 20 40 A. STAKE o ���,
MERINEW
I
a CONCRETE BO UND 9 No.32098
. . _ FENCE F� 9Fc�srER�° a�'® �
( IN FEET ) so��61 LAND
(FND)
1 inch _ -20 ft. -
M.H B.
(FND & HELD)
�w
YANKEE SURVEY CONSULTANTSa: � .� ,
�P
UNIT 1 4OB INDUSTRY ROAD I CERTIFY THAT THIS SURVEY AND PLAN WERE MADE r ,
E �� � da � a , FEB 2 �. 11996
IN ACCORDANCE WITH THE PROCEDURAL AND TECHNIC
P. O. BOX 265
, .,. .:,,. STANDARDS FOR ;THE PRACTICE OF LAND SURVEYING I
;�,. t z .. . .,.. :
MARSTONS MILLS MASS 02�48 T COMMONWEALTH OF MASSACHUSETTS
I
TE'L. 428 -0055 FAX. 420 5553 •PAUL A. MER �DA96
- N P.L` . TE
ITH�` ,'
w GM'' 6 J,¢�50885