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HomeMy WebLinkAbout0046 ELAINE ROAD - Health 46 ELAINE'RD.,HYANNIS T A= i oy_y COMMONWEALTH OF MASSACHUSETTS f fit 167 x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION f TITLE 5 i F0 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES5ME ,I,TSr SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ` ®00 y? 000. PART A �,< CERTIFICATION ' Property Address: Owner's Name. Owner's Address: . 9 A Date of Inspection: Name of Inspector: (please print) `� �� 1 ow, Company NamW11-- $ - Mailing Addre ° Telephone Numkq CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR15.000). The system: /Passes 'Conditionally Passes . Needs urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ✓� The system inspector sha 1 submit a copyof this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner.and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of us e at that time.This inspectiou'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 I Page 2 of l 1 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A Ownerr�� Date of Inspection: z Inspection Summary: Check A B C D or E/ALWAYS p ry AYS 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 availabe. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(.with approval.of Board of Health): broken pipe(s)are replaced obstruction is'removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION(continued) Property Address: r% Date of Inspection: AC"/0c) 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 laboratoryjor 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 tuail 5 ppiii,provided that no,other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSP ECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: Owne Date of Inspection: ✓ /Cry 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 comf onent 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 _ l� 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'/r day flow Required pumping more than 4 times.in the last year NOT due to clogged or obstructed pipe(s).Number ® of times pumped 1 // Any portion of the SAS,cesspool or privy is below high ground water elevation. �i 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 �f are triggered.A copy of the analysis must be attached to this form.] Ile (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 tc correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a.surface drinking water supply _ the system is within 200 feet of a tributary to a:surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water supply well 'P 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART B CHECKLIST Property Address: Y� z Owner ° Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each-of the following: Yes, No t/ 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? L — 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? 1L_ 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)otrthe 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: 6�0' Owner. ' fc i Date of Inspection: Q / FLOW CONDITIONS RESIDENTIAL V Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based oti 310 CMR,15.203.(f�ple: 1.10 gpd x#of bedrooms): ;3 Number of current residents: 'Does residence have a garbage grinder(yes or no)/Ze— Is laundry on a separate sewage system'(yes or nq). `[if yes separate inspection required] Laundry system inspected(ye r no): Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): ,4— Last date of occupancy: ./ COMMERCIAL/INDUSTRIAh✓, Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the ins ection es or no): If yes,volume pumped: gallons--How was quafitity pumped determined? Reason for pumping: TYPE,OF SYSTEM eptic 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): A roximate age of a omponents,date installed if known)and source of information: © �' , 7. Were sewage odors detected when arriving at the site(yes or no):%�/� ® , 6 Page 7 of 11 OFFICIAL INSPECTION FORM.7 NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z7 Owner• " Date of Inspection:_ 0 ej 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:' Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK:Z(locate on site plan) P ) Depth below grade: � Material of construction:_concrete_metal fiberglass. _polyethylene _other(explain). If tank is metal list age:_ Is age confirmed by aCertificate of Compliance(yes or no):_(attach a copy of certificate) ' / Dimensions: 9. .l(&' )',!5— Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: �U Scum thickness: �f Distance from top of scum to top of outlet tee or baffle: 0.. ,f P Distance from bottom of scum to bottom of outlet tee,or baffle:� How were dimensions determined: P r Comments(on pumping recommendations, 'filet and outlet tee or baffle condition, structural"integrity, liquid levels s related t outlet invert, evidence of leakage,etc.): a w aae GREASE TRAA '. die cz si:e r,_an, t De e o Depth I grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee.or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):. 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANK: Mank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBU TION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ��lG,/ j Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of �zjage into or out pf box 'etc. PUMP CHAMBE 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 . ragc Y of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `PART C SYSTEM INFORMATION(continued) Property Address: Date of Inspection: r" SOIL ABSORPTION SYSTEM(SAS): 1/(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation;;: et CESSPOO % L- Tcesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:. Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no):, Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRI��--flvcate 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.): 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: Owne . Date of Inspection: 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. oa a . n 10 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . �'IJZcG� Owner. Date of Inspection: i SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water } 7 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: _,Checked with local excavators, installers-(attach documentation) t/"Accessed USGS database-explain: You must describe how you established the high ground water elevation: I 11 . _ al Y I0*6 Fics..��1.. ............. THE COMMONWEALTH OF MASSACHUSETTS ,r BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Dispm al Workii Tnnitrurtiun tirrutit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: -. 46 Elaine Road, Hyannis, Ma. .. ... ..... .. . .----.....--•------------------- ---------------•---•---••----•-----•---------•--------•----------••---------.......---......._.... Location.Address or Lot No. Dr. David Gianetti _..... ............ .......................................... ..........------•-•-...-•--...................L .••---------••--•--------.................... Owner (� Cash's Trucking Address ,.a -•-••...•---...-----•......---•-•-------------••--------..........-----•-•---------.....---••-••-• ---•-•----••--••••••--------•----..............----••- Installer Address d Type of Building Size Lot...........................Sq. feet U Dwelling No. of Bedrooms.............3 .--.Ex Expansion Attic g— -•--------------------- p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---.....................---- Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter...-----........ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......---.............. fs, Test Pit No. 2................minutes per inch Depth of.Test Pit.--................ Depth to ground water..--.................... 0 W •--••-•••••--•----------••••••-••••-••-••••-•••••••-••••-••-••••-••-••••---•.....-•••••-•....................••----•......••-•••-•--••-• --- ... Description of Soil................................................................................................................................---•------------- x V ....••.......••••••••-••-•-•-••••••---•--••--••--•--•••••••••-•••--------••--•••••••••••••-•••-•••••••••-••-••••••-•---•••-•••••-•--•••••-•••-•-•••••--•••••-••--••••••••-•••--•-••-----••---•-----•-•••. W U -----------------------------------------------------------------------------------------------------------IristalT-•I•;�00-�ga7-Tori�•lioYc�irig--tarik:-�Tristall Nature of Repairs or Alterations—Answer when applicable.......................................................................................*....... ...--••• .. 1,0(70 gallon leaching••pit/4�•..stone packing-----------------•-------•---------------------•--------------------------•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a-Certificate of Compliance has.been iss d by the b rd of health. J 10-05-92 Signed .-.. '._'.�-..,r.. . -: CAS Date Application Approved By .................... Me Application Disapproved for the following reasons- --......................................--------------------------- ------------ -------------------.............................. ----------------- ---------------- p� Date Permit No. ------ ...-....L /�- ------------------------- Issued ........ Date Cd 100 I .'..�- ^ti S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. r TO WN OF BARNSTABLE , Appliration for Disposal Works Tonstrnr#inn 11ami# Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: ___•46 Elaine Road, Hyannis, Ma. _...._»».. .............•----........-------- ....-..............................--------------------------------------------.w......».._. -•Location-Address or Lot No. Dr. David Gianetti -- - --. .............. -------------•-------------------------------- -------------------------------------------------------------------------------»».»_....... W Cash's Trucking Owner Address ••-•••.-- - - -----.... a .._._....- Installer Address U Type of Building Size Lot----------------- ----------Sq. feet .-, Dwelling—No. of Bedrooms.............3........................_...Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Buildin YP g ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. W Septic Tank—Liquid ca.pacity............gallons Length-------------_ Width---------------- Diameter---------------- Depth---------------- x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet---_.____--_--_---_- Total leaching area------------------ ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- 4 Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water____-------________-___. f=. Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water___-_-_--_--___.-_--_--- 0 P4 ------------------------------------------------------------------•----------------------------------------------------------------------------------------- Description of Soil------------------------------------------------------------------------------- V ----------------------------------------------•••----------------------------------------------------•------------------------------------------------------------------------------------ = W ____ _ __ ---- -------------------------------------------------------------------------------------- -------- ----- --- x Install--1,UUU--gallon--holding--tank:"rF9Eall U Nature of Repairs or Alterations—Answer when applicable___ -- 11000 gallon leaching pit/41 stone packin;______._____________________________________________________________________________•-__-_-- --------• -- - - --- g ------------------------------------------------•-•--------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not!to place the system in operation until a Certificate of Compliance has been issued by the board of health. F .l 1.0-05-92 Signed Z / .;r - - -------------------------- ---------------------------------------- [ENSIGN5 S. CASHJ Date Application Approved BY `J V �91 N--------------------------------------------------------------- f -�. c� Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------=---------------------------------------------------------I------------------------------------------------- ------ -------------------------------- Da[e PermitNo. --------7._31--------- ------------------------- Issued ----------------------------------------- -------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ferti irate of (gompliartre THIS ISTO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by Cash's Trucking [POBox 7, Yarmouthport, Ma. 026751 ------------------------------------------------------.....................-------------------------------------------------------------------------------------------------------- Installer at .........#46 Elaine Road, Hyannis, Ma. [Dr. David Gianetti] - -- -------- --------.......................------ -- --------------- ------------------------------------------------ has been installed in accordance with the provisions of TITLE 5 o The State Environmental Code as described in the application for Disposal Works Construction Permit No. --------79�__n... .____ 'dated ------------_______________________.._--.-_-_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. e - ✓ ,DATE ----------------------------------t- - ------------------------ Inspector ----- -- --- i - ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 30 No....---.Q__1_`�D FEE ...---- Dispoottl igorks Tons#rnr#ion famit Permission is hereby granted Gash's Trucking [POBox 7, Yarmouthport, Ma.02675] ___ ---------------------•---------•----------------------•-----------------------------------------------•-------- ....._ to Construct ( ) or Repair (X ) an Individual Sewage Disposal System 46 Elaine Road, Hyannis, Ma. [Dr. David Gianetti] at No-----------------------------------------------------•---------------------------------------•-----------------------------------------------------------------------------------------•----- Street as shown on the application for Disposal Works Construction Permit_No..'_ !M/-__. Dated...........::.::_______:_:.:_:::_._ / ��y Board of Health DATE------------------1--1,. ............................................ v FORM 36508 HOBBS a WARREN,INC.,PUBLISHERS