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HomeMy WebLinkAbout0172 OLD MILL ROAD - Health 172 Old Mill road Marstons.Mills A=064 019 _ Ii Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your A.Riker cursor-do not Name of Inspector use the return key. R.L.C. Company Name � P.O. Box 726 Company Address South Yarmouth MA 02664 City/Town State Zip Code 508-776-6460 SI 4590 Telephone Number License Number B. Certification -`-' c I certify that I have personally inspected the sewage disposal system at this address and that the CIO information reported below is true, accurate and complete as of the time of the inspection.The inspection �r was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: 4.J L Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority 1,21,151,�la Inspector's Signature ` Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. **This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. VV II i � I [Sins•09/08 Title 5 Official Inspection Form:Subsurface a Disposal System• ge 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System was observed to be in operating condition with no failure conditions observed on inspection. System was repaired in 06/02/2006 with installation of new S.A.S. B) System Conditionally Passes: El One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and it a Ceftificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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. ❑ She 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's*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Old Mill Road Property Address Cronin Owner Owner's Name info on is requiredred for Marstons Mills MA 02648 12/15/2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? * ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD bins•09/08 Title 5 Official Inspection forth:Subsurface Selvage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page_ City/Town State Zip Code Date of Inspection D. System Information Description: system was designed for a four bedroom dwelling with a calculated design of 474 GPD Number of current residents: two Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2009=135GPD 2008=165 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Foam Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4.. > 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Homeowner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Pump truck operator Reason for pumping: maintence 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/Altemative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Sight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Approximate age of all components, date installed (if known) and source of information: Existing septic tank is from house construction and D-box and S.A.S.was installed in 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Dry joints with no indication of leakage with proper venting Septic Tank(locate on site plan): Depth below grade: .8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon precast septic tank with PVC baffles on inlet and outlet If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 9,x5,x5, Sludge depth: 2n t5ins-0g108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments H 172 Old Mill Road Property Address Cronin Owner Owner's Name requir required is Marstons Mills MA 02648 12/15/2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Homeowner had system pumped approx. one month prior to the septic inspection . Homeowner was unaware pumping should have been done after inspection.Was pumped as routine maintence only. On inspection there was no scum to measure and under two inches of sludge. System did receive normals water flow prior to inspection . Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date LSins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•39l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. c4rrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at invert of three flow equalizers Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was three feet deep with risers to within six inches of grade. Disribution box had three outlet pipes with flow equlizers installed flowing equally. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-39108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. CillylTown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ® leaching chambers number: 4x 3050 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S.A.S. had no indication of failure on inspection. S.A.S.was constructed of four 3050 infiltrators with four feet of stone around .On inspection there was no signs of hydraulic failure or breakout witnessed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wu s 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins-D9/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Tide 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Q s 172 Old Mill Road Property Address Cronin Owner Owner's Name information is Marstons Mills MA 02648 12/15/2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i 1 Cod C De nSZ5f4,1 t5ins 09W Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Cltyfrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: no water 144" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/02/2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: plan on file with C.O.0 and soil log ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file with deep hole observation . No water encountered and system was installed per design plan .Soil test on 6/02/2006 Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Farm:Subsufface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 172 Old Mill Road Property Address Cronin Owner Owner's Name information is required for Marstons Mills MA 02648 12/15/2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 .rr.,: \ .. _.> f ..- ,._. ..._.. � wrr � dr.r.-rw^s _- .-.- �♦,,,, �- "���'7p•...'"+'�'./1�^Y � rR_. _..-.- {{aa� ._ C ,wwRw. .a*�-.e lF _ _� 'R*� k'iT. ¢T�y� S •d' I M1��.l F9x i�. ��.d���' , {f'� s " '+.f-i..�.w f 6..!_ -..._4—.....,+—_' �..�� � ��.—._.�...o-.. ..a...-... +r},c. J..AI� .'i'� I.. Z' SwF �• � __,,,,��,_�,.�.,,y."v� .y }� .�'r„� —., Y1.—.. — r t i t net X14 i — 3 d q , 0�\ f 1� E EIV :f (o C- a 1 i TOWN OF BARNSTABLE . 1� ATION 01 SEWAGE 00OC-) ' U3 VILLAGE 1"(\ ASSESSOR'S MAP & LOTt29 C� INSTALLER'S NAME&PHONE NO. 9,016 SEPTIC TANK CAPACITY f 00 O G 4\ LEACHING FACILITY: (type) LA) (size)3C� oZ5 y` NO. OF BEDROOMS L( BUILDER OR OWNER Ctvw �✓� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _N�r_ Feet Edge of Wetland and Leaching Facility(If any wetlands exist r within 300 feet of leaching facility) �6 Feet Furnished by %N t I S F r ,fir �, �.'l �' � o ���� �G—G�a1� i v lyjplAl (�oIVS ��U c Tie) �o eQle& - oGy_ vim A no deC wit L r � q No. —3p3 OOL t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE.MASSACHUSETTS 01ppUration for Migpoml *p5tem Con!Aructiou Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) El Complete System Individual Components Location Address or Lot No. PIZ Ql l el. t A/l Owner's Name,Address and Tel.No. Assessor's Map/Parcel C Installer' Name Address wand Tel No. Designer's Name,Address and Tel.No. ovJ�'re Id SAvtt F,a�,.y se✓v. 1NL ®$c- Q4cllr SOX YctZ f.-oie��'�OZto�F�/ �<cJ'� 201 o or-.3 2f77 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building S` o.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z/79.0-0 gallons per day. Calculated daily flow �7��i� gallons. Plan 'Date In _a —©G Number of sheets Revision Date Vm/%A--"-_ Title Size of Septic Tank IMQ 'e i Type of S.A.S. 30Q) r®'1 oC/fT//4AL,__S' Description of Soil J'`.A47 Nature of Repairs or Alterations(Answer when applicable) a r Gt% 35 ji,50 / crzr��us� wj ^ J 7c itl� 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 Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y this and of Health. Signed Date 1� Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 7 S No. t3 . Fee t - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: P' Yes PUBLIC HE, LTH DIVISION"TOWN OF BARNSTABLE, MA.SSACHUSETTS Appl-tcati-on for ;Dioaal *potem Cougtructiou Permit -Application for a Permit to Construct(V� )Repair(,k/)Upgrade( )Abandon( ) ElComplete System XIndividual Components J; I Location Address or Lot No. 2�O4.M14 J lMAA Owner's Name,Address and Tel.No, eraNr✓I Assessor's Map/Parcel Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. a , 13ox L(g7- r=7ae� 'd-4(b2(0 qy ° e�Pt ��.,�� 21.7 Type of Building: Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder( -•) Other Type of Building o. of Persons Showers( ) Cafeteria( ) Other Fixtures s Design Flow ���r iM gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date 01Div-4— Title Size of Septic Tank r Type:of S.A.S. 3C� �/ �'.4fL �'' \ �— Description of Soil• -PW 944ten Nature of Repairs or Alterations(Answer-when applicable) 1 n 7' l/1/ v ✓ ,Yti J / ..✓/ / 70 ,x 1 � �a 111 Date last inspected: �•M. 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 Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. / Signed Date Application Approved by Date Application Disapproved for the fo owing reasons Permit No. /. ...- "'�f"� _ Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,eMASSACHUSETTS Certificate of ttCbmpliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(,r )Upgraded( ) ti Abandoned( )by ;36t j P //� fO,,�I..64efe C at / e /c�/c�//y!.%/ ?J.✓ �4!i.4, _has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit No.-'20 0 61 ')`mated-6 r 4 Installer�&v Id 4'.'l. &-� ���ili l c�Designer /�/�e e. 7v i The issuance of this permip a not 4e construed as a guarantee that the' M nction as designed. Date ! �i Inspectors' 1 ' No. Q(-)n l Fee /46 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS =igpogal 6pgtem Con!Aructiou permit Permission is hereby granted to Construct( )Repair(,I")Upgrade( )Abandon System located at /72 /d./.,� /L. Aa�-4- 0�6— r 41 4Z < t 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. Provided:Construction ust b completed within three years of the date f this pe it t• Date:_ 5 Approved by ( ''� Town ®f Barnstable Regulatory Services Thomas F.Geller,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-7.90-6304 Installer&Designer Certification Form Date: Designer: —Dibeo g) -6. MA�v� Raj Installer: J�Vlc'e Z,ic Address: . Address: IZ,60�—I IPwlOA MIA o z G,_ra On Bou SF(•e (A was issued a permit to install a (date) (installer) septic system at MP M I I-L l�l?,M -(bV4� M 1 LL5based on a design drawn by �, (address) - c V lV Y%DU-41 V'�' dated 2 2D n / (designer) 1/ certify that-the septic system referenced above was installed substantially according to the design, which may include minor approved"changes such as lateral relocation of the distribution box and/or septic tank- I certify that the septic system referenced above was installed with major changes (I' - - greater than 1.0' lateral relocation of the SAS or any vertical relocation of any component of the.septic system)but in accordance with State&Local Regulations. Plan revision or certified as built by designer to follow. - t 0F�`��q DAM �y y (hisadleys Si6 maluftj g MASON co y o No:1066 "► - � ,�j v ���iSTEP�4 •y s�A.1TAt���� (Designer's Signature) (�X er's Stamp. ere) PLEASE RETMN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTJ(FiCATE OF CONW4. NCE - NOT BE ISSUED UN'I'IL BOTH T.S FORM AND AS- BUIL3'CARD ARE RECEIVED BY THE BAIElNSTA$LE PUBLIC REALTHI)MSI6N_. THANK YOU. Q:HealthfSeptic/Desig er Ce tification Form AA + - - - - --- �- -- a- t ic �,�ptnflNff�3yi ! ti J( s\ s .,tom_� ,•,ti i 1..•_, :r - _ s .S` r•t S V { ..r. J y ! .�1 �.. ~\ , .+t�. J e, ` � }� S`is r � • n , .. \ . I 1. J •* }• , i�.• , ._.._ .._ +1 ' � s \ l` ` `..1. ;,) C. �e' �• ' �� �� . . } tit �.- � ; s i 4: 1 v �7� 17&.ct1' rrovara00,0 at runs ant] a2EWllV� rVurn f 17 fir r. IrlAr'�1 t%%J The plans and specifications for every on-site system shall be prepared as follows: (1) Every system shall be designed by a Massachusetts Registered Professional Engineer or a Massachusetts Registered.Sanitarian provided that such Sanitarian shall not design a system designed M scharge more 114112.000 gallons Per day puusuant to 310 CMR 15.203. My odic;+agpt o(1°ilis owner may prep plans for the repair of a system designed to ischarge not more than,than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they.are reviewed by a"achusetts Registered Sanitarian a approved by the approving authoi3ty;,; .. . (2) Every plant submitted for approval must be dated and bear the stamp and signature of the ddiignter,: :...;. y.-t W.�. 1 (3) Every plan:: r a new system.or plan for the upgrade or expansion of an existing system which requires.a variance to a property line setback distance.'must.also reference a plan which bears the stamp and signature of a Massachusetts: Licensed Land Surveyor in accordance with M.G.L.c. 112, I: S ID; ,_14) Every plan for a System shall be of suitable scale(one inch 40 feet or fewer for plot plans and one inch a 20 feet or fewer for details of system components) and shall irtclude dy tron of. ✓ (a) the legal boundaries of the facility to be served: /(b) the bolder and location of any easements appurtenant to or which could impact the . ✓ system; /(c) the location of the all dwcWng(s)or building(s)existing and proposed on the facility . V and identification of those to be served by the system; >td) -the'iacation of existing or proposed impervious areas, including driveways and 1/ idng areas: e) location and dimensions of the system(including reserve area); ( system design calculations,including design daily sewage flow,septic tank capacity equired and provided): soil absorption system capacity (required and'provided); and VVV ether system is designed for garbage grinder. (g) North arrow and existing and proposed contours; location and log of deep observation hole tests including the date of test,existing grade elevations rr.aiked on each test. and the names of the mpreientativc of the VVV a authority and soli evaluator; I) location i) location and results of percolation tests including the hate of test and the names of V/ representative of the approving authority and soil evaluator, (r7 name and ceni5ration number of the Soil Evaluator of retard; (k) lomdon of every water supply,public and private, 1. within 400 fat of the proposed system location in the case of surface water supplies and gravel,packed public water supply wells, 2. within 250 feet of the proposed system location in the case,of tubular public water supply wells,and 3. within ISO feet of the proposed system location in the case of private waaer' supply wells' —"` location of any surface waters of the Commonwealth. rivers, bordering.vegetated wetlands, salt marshes, Inland or coastal banks, tegulatory flcodway, velocity zone, surface water supplies.tributaries w surface water supplies,certified vetnal'gaols,private water supplies or suction lines, gravel packed or tarbtrlar public wa" -supply wells,. subsurface drains,leaching catch basins,or dry wells: and the location.of aly nitrogen sensitive area idenMcd'in 310 CMR 15.215 within which portions o `'th proposed r11 tent are lotted. m) location of war lines and other subsurface utilities on the facility; observed and adjusted ground-water elevation in the vicinity 6f the system .. o a complete profile of the system; (p) a note on the plan ltstigg all variances to the.provisions of 310 CMR 15.000 sought •�' in conjunction with the plan: �(�} the location and elevation. of one benchmark within. 50 to:.7S feet.of the facilit)+ V which is not sbbjcct to dislocation or lass dent g.ccrosttaction ori'the facility. W when dosing is-proposed.completa;1:l ip and specification of the dosing system► , proposed including but not limited to do.;ing chamber capauaty(ru;gttised and provided),; ' pump curves and sp�ficadons,number:af.daring cycles and depth ger cycle; when a Recirculating Sand Filter or:egWvalent almmadve technology isregttinrtl or ; J•/f f roposed,a complete plan and sp=cation for the system,including it hydraulic profile .., a luaus plan,to show the location of`1h.o facility including the nearese existing'stt fi, u the street number and lot number,if any,of thc-facility;and , Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only • PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, VID -5• ft5W. RS , hereby certify that the engineered plan signed by me datedTVQE Z�7-00J�- concerning the property located at 117, 00 MIu, Roil-0,M�� MU-5 meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet.above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using.the Frimptor method when applicable] ` Please complete the following: y� A) Top of Ground Surface Elevation(using GIS inforinkion) - 9�/0n. B) G.W. Elevation +adjustment for high G-.W. DIFFERENCE BETWEEN A and B SIGNED DATE: i✓ Z ,� NOVICE , Based upon the above information;A repair permit will be issued for bedrooms maximum. No additional Bedrooms are authorized in:the future with' in engineered peptic system plans. q ASeptic%percexemp.doc No........a7.6........ Fim...,, ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0/,F HEALTH _ �� l ......O F............. .. � � --� ...........-..... Appliration for Roputial Workti Tan,13 urtion 1krmit Application is hereby made for a Permit to Construct (" ) or Repair ( ) an Individual Sewage Disposal .System t Location-A"esssj - or Lot No. - �• _ ''. !'.......................• .......................•-•---------. ----------------------- • ner Address a /i { ---------------•-••••......• Install 7 Address Type of Buildi><lg/ Size Lot............................Sq. feet U Dwelling /—/No. of.Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) U Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............ ----------------------------------------- � � a-�------------------r----....------- W Design Flow.................. ......._.....gallons per person per day. Total daily flow........... .- ...._-...-...gallons. WSeptic Tank- -Liquid capacity gallons Length................ Width................ Diameter.....---.--..... Depth................ x Disposal Trench— o..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... ..... ...... Diameter.....--.--.......... Depth below i t.... ...... ... Total lea hing area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performedby.............................................................. ate........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit..--................ Depth to ground water........................ --------------- .... / -- o _. - : Desc.iption of Soil .. -----/,Y- .....:::�­/-;t----1, -------------------------- V --------•-••-----------------------------------••••••-•---------------------------•--•-----------------•------------•---••••----••------••.......•---•-•••-•-•-----•--•-••--------••-------------------- W ----•---------------------••------------•---•------•-------------•---------•--•-•••--•------------••--•--•-•••-•---•--••-•-----•-•---•-------•---------------------•---•-------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ---- -•-----•--------------•............•-----------•------•-•-•........••------...•----••••-•-................--------•--••----•--•-••-----•••--•------••-----••-••-•---•-........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of. Compliance has been issued by the board f health. ned-- - -------- --------------- ..r' _------ -------------------------------- Date Application Approved BY........... , --.... - -���� Date Application Disapproved for the following reasons-----------------------------•----------------------------------•----------------•---•-------•---••-•-•-•....••-- r K ........-•--------•-----•-----•-----------------------------------------------------------•.......----....---- --------�-••-•-•--••--••-•-......---------- Date �• :.Permit No.-•-••--•----•-••-•-•-•-----•-------•---•................. Issued. �....•` ---------------•-- Date -- •---�y.�__�.._-------_��_---- ----------------------------- No.--•--74.-....... FEE.. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH .............OF...... Aptiration for 31 hip al 10orks Ton urtinn r:MMif Application is hereby,made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System,,at: IIJJ�� � �/�{{//ff'�� 4R0. Location• essor L - - �---- ••••r--•--.....••-••------•-•.. ....................••--••.....-..._._.....••••••••...•---•-•-••-••••--•-•----..... .. - ner � Address -. ........................ ................. . .......•-••................ ns alley Address Q Type of Build* Size Lot............................Sq. feet a Dwellingo. of Bedrooms ______________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtur s --------------•-----•--•------------••-----•----•-------------••-•-•-•----------------•-----•-•----- W Design Flow.................. ..... ........... gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank Liquid capacity gallons Length---------------- Width................. Diameter................ Depth................ x Disposal Trench— o_____________________ Width.................... Total Length______._.___._.:._:_ Total leaching area....................sq. ft. Seepage Pit No r______. Diameter____________________ Depth below let/ Total lea hing area__ sq. ft. Z Other Distributiontox ( ) Dosing tank ( ) •";, I�OL.7 ify a Percolation Test Results Performed by.......................................................................... Date------------........................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water—..................... � •---.........�q r O Descripiion of Soil...r-....................L�... .._ ....... ..... '°. ' (� UNature of Repairs or Alterations—Answer when applica.ble...........................................:................................................... - -------------------------------------------------------------------•-••--••---•-------•-----•-...---------------•--------------..................-----•--------------......-•-••-••-__•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary.;Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board,4 health. ,�ned_. j -•-•- ......... ................................ Date ---------- Application Approved B PP PP y------ G - _ .. , �f �.. Date Application Disapproved for the following yedsons:. --1-'------------------•-----------....-------•-••--•-•••-------•.....••- --•-------------------------------•------.....---•----------------------------------••--------___-_-_---------------•--•------------------------------ ---....___.... • Date ..... Permit No......................................................... Issued...... ,/ Date j ,y THE COMMONWEALTH OF MASSACHUSETTS BOARD F' HEALTH ........................OF.... �1...» . .................................................... 'f irate of Tompliana T S CERTI at ndividual ewage Disposal Syste constructed ( ) or Repaired ( ) VIA has been installed in accordance with the provisions of Article o The State Sanitarye > des ibed m th application for Disposal Works Construction Permit No...__._---- dated ------------ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DA1TE................................................................................ Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFj,4EALTH iklon .....0•F............. `' ._ .:...........•--........... No......:. fx . ..�. ..�- ....... - � FEE---- �......... Permission is by'granted.--- . . . ......... •- --• • .. ..................... ..... ..... .... ,r to C st ct ( ) or Repair, ( ) an Indivi ew yst at eN9 � Street as shown on the application for Disposal Works Construction Permit No..................... Dated................................ ....... ............................................ ............................................................ Board of Health r DATE................................................................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS I • 'L 1 BARNRTAXLE COUNTY HEALT73C DEPARTMENT • 13AW48TABLA MASS. 02680 h T[LQMNON[- 362-2511 Fact- 331 . Date: January 31, 1974 I• • To: Oman Construction .5200 Building West Yarmouth, Mass. 02673 On the basis'of a sanitary survey and a laboratory examination on the: sample of water taken from a ....�e�l,.,., located on the premises of, Oman. Construction. . . . . . ..... ._.. , located at Lot 276 ad.,. )stic.-Iakey Iarstons Mi °n _j4nu07.'29, -19714..4... QId.:Ma11P . (Date) this supply is approved for domestic purposes at the time the examination was made. If you. wish further information regarding this supply, please contact us at the County Court House, Barnstable, Massachusetts (Tel: 362-2511 Ext.. 3314 and we wiL1 be glad to assist you. in any way possible. _/ a� cc Barnstable Board of Health Signed: • • Hyannis) Mass 02601 Public Health Sanitarian a W.H-. Hackett Well Drilling Bettys Pond Road Hyannis, Massachusetts 02601 i ..._........�._....,.._r—,., ,..-�m.�,,..M,�.,.,,..,.,,...•.�.,�,,.„.,,.,�.»,,,_.._.r..�.,...__._,,,...,�,,,,,,mar,,•,„r....,., ..�.-....,.,,,.. ,.�,.,.,�...,.,.,,..,:.,.,.�; ^ r. _ r /oll �( L/ q i ASSESSORS MAP: - __----- TEST HOLE LOGS PARCEL. -- NOTES: __ _ �► 1 FLOOD ZONE: do-T. iPPL1G�l�-fi SOIL EVALUAT R: PAVID �• • REFERENCE: covi T�1 � 11 WITHE33: 1 : __ -_ DATE• 1) The installation shall comply with Title V and Town of Barnstable Board of PERCOLAT I ON RATE: 4 2 . 1 Health Ugulations. 2) The installer shall verify the location of utilities, sewer inverts and septic 4 la" _� ;%,w t itZ �✓ components prior to installation and setting base elevations. TH-i .. TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first - two feet out of the dbox to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other /.� purpose other than the proposed system installation. a 1 q • / L53 5) All septic components must meet Title V specifications. 4J LOCATION MAP �) Parking shall not be constructed over H10 septic components. Cv413). 1OW. ler),twiyp ) The property is bounded by property corners and property lines. 8) The property ourner shall review designzonsideratlons to-approve of total (IfEQ, �4+�� Ct design flow and number of bedrooms to be considered for design. Receipt of ' L 1 , 70 1 payment for the plan and installation based on the plan shall be deemed I approval of the design flow by the owner. p rwithin9) The existing leaching or cesspools shall be pumped and filled with material'0 per Title V abandonment procedures. Those within the proposed SAS shall be I\ \ 4 o� w removed along with contaminated soil and replaced with clean washed sand -- ►�O �.IIJchT2�. � �Lh►,e per Title V specs. 10)System-components to be 10-feet from waterline. Sewer lines crossing the SEPTIC SYSTEM DESIGN / water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if \ \ applicable: `�� °) \ 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW EST 1 MATE owner to ensure such. 12)The installer is to take notion in excavation around the gas line if applicable. BEDROOMS AT I D GAL/DAY/BEDROOM -qqo GAL/DAY SEPTIC TANK - I � GAL/DAY x 2 DAYS - 4 GAL IDD WE IODD GALLON SEPT I C TANK' 1 fs I 1 ' •� f� t� � ; 417 301L AB ORPTION SY TEM �flT: fluAvAlf, 5 == L rho 6 u�40U- OF _tjov _�. �. � ICI p ,o� �a - DAVO S l DE A1TEA• ZX 34 i -- 02� 2-K ► - :��� - �- ? �,/�_p_�2_` Q ddK ,—/� ' �._ •�,� BOTTOM AREA: {� l �2 ��1 = MASON B. `�' y no.ING NIL IZoA � 't ITA -----------_ ..--- -- ------- -- — S IC SYSTEM SECT I ON op of CAL �7 - � - 0 1 ° 0 0 1 j I .i�w Ley SEPT I C TANK o p 0 -o 0 0 0 0 8ZA0 I 'DDV91,4, _i0Tj OF 1W HOGC CZZV, 7�oD SITE AND SEWAGE PLAN 4T LOCATION : 17Z �-D p'�11 J IDWD ,Sol 149 PREPARED FOR v/� C�2or•.// / 074 SCALE: DAV 1 D B . MASON,Rs DATE: Z D DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA (508 ) 833-2177 II i I I