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HomeMy WebLinkAbout0258 MONOMOY CIRCLE - HAZMAT 25 Moi ornoy Circle �ea��erv;l le - A�'= 191214 S ME:A D No. H163OR UPC 10259 smead.com • Made in USA �J 2� r � z� Certified Mail#7003 1680 0004 5458 2209 �ofr�yy Town of Barnstable Regulatory Services nARNWASM Thomas F. Geiler, Director Q„ +A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 3, 2005 Meredith McClave 2720 Royal Drive Winterville,NC 28590 NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE CODE. The property owned by you located at 258 Monomoy Circle, Centerville, MA was inspected on June 3, 2005 by David Stanton R.S., Health Inspector for the Town of Barnstable, because of a complaint. Also present during the investigation were the Town of Barnstable Police, Building Commissioner, and COMM Fire. The following violation of the Town of Barnstable Code was observed: Town of Barnstable Code 4170-7: Owner's name, address and telephone number were not posted outside. Town of Barnstable Code §170-7 reads as follows: An owner of a dwelling which is rented for residential use,who does not reside therein and who does not employ a manager or agent for such dwelling who resides therein, shall post and maintain or cause to be posted and maintained on the exterior of such dwelling within five (5) feet of the main entrance or within five (5) feet of the mailbox(es), at least four(4) feet and not greater than six (6) feet above ground level, a notice constructed of durable material, not less than twenty square inches in size, bearing his/her correct name, address and telephone number. If the owner is a realty trust or partnership,the name, address, and telephone number of the managing trustee or partner shall be posted. If the owner is a corporation, the name, address, and telephone number of the president of the corporation shall be posted. Where the owner employs a manager or agent who does not reside in such dwelling, such manager or agent's name, address, and telephone number shall also be included in the notice. You are directed to correct the violation listed above within Thirty (30) days of your receipt of this notice by posting the building properly per the Town of Barnstable Code §170-7. Q:Order letters\Housing violations\258 Monomoy Circle.doc r You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance could result in a fine of$40.00. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S. Director of Public Health Town of Barnstable Q:Order IettersMousing violationN58 Monomoy Circle.doe f t DER-COIWPLETE THIS SECTION • • ON DELIVERY o"Complete items 1,2,and 3.Also complete'` A. Si nature item 4 if Restricted Delivery is desired. ❑Agent ® Print your name and address on the reverse X G MC I C f ❑Addressee So that We can return the card to you. B. Received by(Printed Name) C. Date of Delive ■ Attach this card to the back of the maiipiece, /' or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes e - If YES,enter delivery address below: ❑No ���e(�e(�f r'� �C C I�✓I Q �'� 'j Drew Y :U 3 At w I ml2-(Ljlei IUC- ?8S o `'- Certlfled Mail ❑Express Mail ❑Registered WRetum Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (transfer from service iabeq 7.003 1680 0004 5458 2209 PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 p-- . �:• srttk�ar�: ,,+, ems" :� - > a ni Cc Ln LP) Postage $ E3 M� a Certified Fee o , 30 ��45 paw O Return Reciept Fee Postmark (EndorsementRequired) Here O Restricted Delivery Fee JUN6 200�5 CO (Endorsement Required) .A r 1 Total Postage&Fees m Q Sent To / r-3 Mei eC�lr f� I~ Street, `�'CC2Q. Apt No.; -- or PO Box No. - City State,Z%P+4-----------------ev � NC ,, 04l S------------------ Health Complaints 06-Jun-05 Time: 12:05:00 PM Date: 7/22/2004 Complaint Number: 17592 Referred To: DAVID STANTON Taken By: DAVID STANTON Complaint Type: CHAPTER II HOUSING Article X Detail: ILLEGAL OPERATIONS Business Name: Number: 258 Street: Monomoy Circle Village: CENTERVILLE Assessors Map_Parcel: Complainant's Name: ANONYMOUS Address: Telephone Number: Complaint Description: TOO MANY PEOPLE LIVING IN THIS HOUSE, MORE THAN 3 UNRELATED FAMILY MEMBERS, TONS OF CARS PRESENT. Actions Taken/Results: DS WAS WAITING TO MEET WITH BUILDING FOR A JOINT INVESTIGATION, BUT OUR SCHEDULES JUST WEREN'T MATCHING UP WHERE WE COULD MEET THERE AT THE SAME TIME TO INVESTIGATE THE COMPL•AINT.. DS WENT TO SAID LOCATION. THERE WAS ONE CAR IN THE DRIVEWAY, AND TWO CARS ON THE LEFT SIDE OF THE HOUSE. ALL THREE CARS HAD PLATES ON THEM. DS SPOKE WITH EUGENIY BRONOV. DS EXPLAINED THE REASON WE WERE THERE, AND HE SAID THAT THERE ARE SIX PEOPLE LIVING AT THE HOUSE NOW. HE STATED THAT THEY HAVE THREE BEDROOMS IN THE HOUSE, AND THERE ARE TWO PEOPLE IN EACH BEDROOM. HE SAID THAT ONE OR TWO OF THE TENANTS MAY BE MOVING OUT. NO BOARD OF HEALTH VIOLATIONS OBSERVED. BUILDING/ZONING ENFORCES THE MORE 1 Health Complaints 06-Jun-05 THAN 3 UNRELATED FAMILY MEMEBERS IN A SINGLE FAMILY DWELLING. IF THIS PROBLEM PERSISTS AND WE CONTINUE TO GET COMPLAINTS, HEALTH DIRECTOR TOM MCKEAN MAY WANT THIS FOR THE BURST TEAM IN THE FUTURE. ON 6005, WE CONDUCTED AN ALL DEPARTMENT INSPECTION WITH BUILDING (TP), COMM FIRE (MM)AND BARNSTABLE POLICE. E- MAIL IN FILE OF INVESTIGATION. ORDER LETTER SENT TO POST HOUSE PER TOWN ORDINANCE. Investigation Date: 8/13/2004 Investigation Time: 3:45:00 PM 2 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date Ow ner Tenant Address ew6Nt 1 Address Compl!once Remarks or Regulation# Yes No & Recommendations 2. Kitchen Facilities /W ) 3. Bathroom Facilities _ b( Jdy 4. Water Supply / 5. Hot Water Facilities IT 6. Heating Facilities l (� 1 7. Lighting and Electrical Facilities 8. Ventilation �l/(,IG �. fv,/ GJ` 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use vc i 12. Exits 13. Installation and Maintenance of Structural o Elements 42 LJ a�) 1 O 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal k ni 6 IZ. 17. Temporary Housing PART II OJ'�i Utilv��'S �y✓vl�. 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here Vy fvvA&mv,- c"r, l4o17 1 W-C CIVA Town of Barnstable, Building Commissioner: Tom Perry 200 Main Street Hyannis MA 02601 Jason Laber 268 Monomoy Circle Centerville MA 02601 508-790-4905 Dear Sir, July 28, 2004 I would like to make a formal complaint regarding the residence at 258 Monomoy Circle, a single-family three bed/two bath dwelling located in the RC District. Meredith McClane,who has recently moved to North Carolina, owns the home. The home is being rented to five non-related adults. Peter McClane, the homeowner's husband, told me that they are renting the home for at least one year in a recent conversation. Several Section 3 and 4 violations can be regularly observed at 258 Monomoy Circle. I fear that some of the violation(s)have the potential to "spill over"into Health related issues (septic failure, garbage removal issues, etc...). The home is being inhabited by more than three(3)unrelated adults. The driveway cannot accommodate the number of vehicles (at least five—often times more). Vehicles are often times forced to park on the street overnight. The traffic generated over the past month has been in excess of normal residential volume. Traffic has never been an issue in our neighborhood until recently. Our concern(s) are obvious—we want to maintain a reasonable quality of living. We want our neighborhoods to remain family oriented - and rely on the towns ordinances to protect our interests. Our concern(s) are not with the current tenants -they have been considerate,respectable and kind. However,the home has become a"rooming-house" and we feel that we should have had the opportunity to make public comment suggesting our concerns. I have recently collaborated with a number of Monomoy Circle and Thoreau Drive neighbors regarding 258 Monomoy Circle. We feel that our issues would be resolved if the McClane family would consider and abide by the clearly defined regulations pertaining to residential rental homes in the RC District. I ask that you help us by enforcing the continued violations at 258 Monomoy Circle. If you need more information and/or violation verification(s),please feel free to contact me at the above telephone number. Sincerely, Jason Laber Geiler, Tom From: Klimm, John Sent: Tuesday, September 21,2004 10:15 PM To: Geiler, Tom Subject: FW: 258 Monomoy circle In Town of rnstable.doc(20 KB; Tom- Please investigate. John -----Original message----- From: Laber, Jason [mailto:laberj@barnstablepolice.com] Sent: Tue 9/21/2004 1:03 PM To: janetjoakim@aol.com Cc: Subject: 258 Monomoy circle Hi Janet, My name is Jason Laber and I was unable to reach you on your phone (508-420-2153) . I just wanted to touch base about an issue with our neighbors at 258 Monomoy Circle. The neighbors and I are concerned with the amount of residents renting the home (over six unrelated adults) , and feel that the Town Ordinances are being violated. I have sent a letter to the Building Department on July 28, 2004 and have also informed (in person) the Health Department. I received correspondence from the Health Department, but have not yet heard from the Building Department. The Health Department made an inspection on August 13, 2004. Dave Stanton found that there were six adults living in the home. Eugeny Bronov apparently told the inspector that one or two tenants are going to move out - but this has not been the case. The reality is that there appears to be even more tenants and vehicles at the home. There are sometimes over seven cars parked in the driveway and on the road. According to David, Building/Zoning is responsible for enforcing these ordinances. We are growing increasingly concerned and thought that you might be of help. Our "family oriented neighborhood" traffic has grown to unreasonable proportions while cars pass through at all hours at unecessary volume. Cars are continually parked in the road due to the lack of space in the driveway. We feel that this is not only becoming a safety issue, but will ultimately evolve into other issues as well. Please feel free to call my wife (Jennifer) and I at 268 Monomoy Circle at your earliest convenience. We are usually home in the evening and would love explain this issue further. I have also attached a letter that I sent to the Building Department - registered mail. Thank you for your time, Jason and Jennifer Laber 268 Monomoy Circle Centerville, MA 508-790-4905 <<Town of Barnstable.doc>> 1 Message` Page 2 of 2 people living in the home. We were never told the outcome of the investigation/action as a result of our complaint. Were there any fines levied against the homeowner? Why does this continue to be a problem for us? On behalf of a handful of nearby families, I would like to open lines of communication and express the complexity of the problem. Perhaps you could clarify how the town enforces these regulations—as this is confusing. I know this is becoming a problem throughout the town(as neighbors on the other side of Monomoy Circle have also communicated similar problems to me). I am passionate about working together to preserve our neighborhood. We look forward to your reply and will be happy to provide you with further information(digital photos, etc....). Your constituent, Jason Laber email from last fall: Hi Janet, My name is Jason Laber and I was unable to reach you on your phone (508-420-2153). 1 just wanted to touch base about an issue with our neighbors at 258 Monomoy Circle. The neighbors and I are concerned with the amount of residents renting the home (over six unrelated adults), and feel that the Town Ordinances are being violated. have sent a letter to the Building Department on July 28, 2004 and have also informed (in person)the Health Department. I received correspondence from the Health Department, but have not yet heard from the Building Department. The Health Department made an inspection on August f3, 2004. Dave Stanton found that there were six adults living in the home. Eugeny Bronov apparently told the inspector that one or two tenants are going to move out but this has not been the case. The reality is that there appears to be even more tenants and vehicles at the home. There are sometimes over seven cars parked in the driveway and on the road. According to David, Building/Zoning is responsible for enforcing these ordinances. We are growing increasingly concerned and thought that you might be of help. Our"family oriented neighborhood"traffic has grown to unreasonable proportions while cars pass through at all hours at unecessary volume. Cars are continually parked in the road due to the lack of space in the driveway. We feel that this is not only becoming a safety issue, but will ultimately evolve into other issues as well. Please feel free to call my wife (Jennifer)and I at 268 Monomoy Circle at your earliest convenience. We are usually home in the evening and would love explain this issue further. I have also attached a letter that I sent to the Building Department-registered mail. Thank you for your time, Jason and Jennifer Laber 268 Monomoy Circle Centerville, MA 508-790-4905 Janet Swain Joakim Barnstable Town Council janetjoakim@aol.com 508-420-2153 www.janetioakim.org 5/31/2005 14jae ct a //lP Cctre e ! On OAS une - I I F Health Complaints 19-Jul-05 Time: 12:05:00 PM Date: 7/22/2004 Complaint Number: 17592 Referred To: DAVID STANTON Taken By: DAVID STANTON Complaint Type: CHAPTER II HOUSING Article X Detail: ILLEGAL OPERATIONS Business Name: Number•_ reef. onomoy Circle Vill ge: CENTERVILLE Assessors Map_Parcel: Complainant's Name: ANONYMOUS Address: Telephone Number: Complaint Description: TOO MANY PEOPLE LIVING IN THIS HOUSE, MORE THAN 3 UNRELATED FAMILY MEMBERS, TONS OF CARS PRESENT. Actions Taken/Results: DS WAS WAITING TO MEET WITH BUILDING FOR A JOINT INVESTIGATION, BUT OUR SCHEDULES JUST WEREN'T MATCHING UP WHERE WE COULD MEET THERE AT THE SAME TIME TO INVESTIGATE THE COMPLAINT.. DS WENT TO SAID LOCATION. THERE WAS ONE CAR IN THE DRIVEWAY, AND TWO CARS ON THE LEFT SIDE OF THE HOUSE. ALL THREE CARS HAD PLATES ON THEM. DS SPOKE WITH EUGENIY BRONOV. DS EXPLAINED THE REASON WE WERE THERE, AND HE SAID THAT THERE ARE SIX PEOPLE LIVING AT THE HOUSE NOW. HE STATED THAT THEY HAVE THREE BEDROOMS IN THE HOUSE, AND THERE ARE TWO PEOPLE IN EACH BEDROOM. HE SAID THAT ONE OR TWO OF THE TENANTS MAY BE MOVING OUT. NO BOARD OF HEALTH VIOLATIONS OBSERVED. BUILDING/ZONING ENFORCES THE MORE 1 Health Complaints 19-Jul-05 THAN 3 UNRELATED FAMILY MEMEBERS IN A SINGLE FAMILY DWELLING. IF THIS PROBLEM PERSISTS AND WE CONTINUE TO GET COMPLAINTS, HEALTH DIRECTOR TOM MCKEAN MAY WANT THIS FOR THE BURST TEAM IN THE FUTURE. ON 6/3/05, WE CONDUCTED AN ALL DEPARTMENT INSPECTION WITH BUILDING (TP), COMM FIRE (MM)AND BARNSTABLE POLICE. E- MAIL IN FILE OF INVESTIGATION. ORDER LETTER SENT TO POST HOUSE PER TOWN ORDINANCE. DS WENT BACK TO SAID LOCATION ON 7/13/05 TO FOLLOW UP ON THE SIGN POSTING. NO SIGN OBSERVED. DS SPOKE WITH A TENANT, BUT IT WAS HARD TRYING TO TRANSLATE\INTERPRET. DS CALLED OWNER IN NC AND SPOKE WITH DAUGHTER, LEFT MESSAGE TO PLEASE CALL ME BACK. MERIDITHS NUMBER IN NC IS (252) 321-6655. DS CONDUCTED A FOLLOW UP ON 7/18/05 AND THE SIGN WAS POSTED ON THE LEFT SIDE OF THE FRONT DOOR. NO FURTHER ACTION REQUIRED. Investigation Date: 8/13/2004 Investigation Time: 3:45:00 PM 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: 258 Monomoy Circle cAlp Property Address McClaine Owner's Name Owners Address Centerville MA 02632 City/Town State Zip Code Date of Inspection: 8117/06 Date 2. Inspector: Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd. Company Address Mashpee MA 02649 City/Town State Zip Code 508.272.6433 s Telephone Number E 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 `I sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F rthe aluati y the Local Approving Authority 8117106 Inspectors ltrAarurei 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. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form A. Certification (cont.) 258 Monomoy Circle Property Address Centerville MA 02632 Cityrrown State Zip Code McClaine 8117/06 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) 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: n/a Title 57remplate.doc•11/2004 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 258 Monomoy Circ. Property Address Centerville City/rown State Zip Code Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a 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 Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form M A. Certification (cont.) 258 Monomoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(cont.): 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: n!a **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. 3. Other: Title 5Template.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 268 Monomoy Circ. Property Address Centerville City/Town State ZipCode Owner's Name Date of Inspection 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 ❑ 0 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 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E! 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.] 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. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form ' M A. Certification (cunt.) 268 Monomoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection 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. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form N B. Checklist 258 Monomoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form o Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 258 Monornoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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: Last date of occupancy/use: Date Other(describe): Title 5Template.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M y+ y C. System Information (cunt.) 258 Monomoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: System upgrade 1997(2 leaching chambers). Home built 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5Template.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cunt.) 258 Monomoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2'6" feet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10, feet Comments(on condition of joints, venting,evidence of leakage, etc.): no adverse conditions Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ® No certificate) Dimensions: 1000g Sludge depth: s.. Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle >2.0 Distance from bottom of scum to bottom of outlet tee or baffle >2.. How were dimensions determined? measured Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form M C. System Information (cont.) 258 Monomoy Circ._ Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): no adverse conditions exist Grease Trap(locate on site plan): Depth below grade: n/a 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 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: n1a Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 9 Title 5Tem late.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 268 Monomoy Circ Property Address Centerville Cityrrown State Zip Code Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: n/a 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.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level w/bottom of the pipes Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is level :, distribution to the chambers is equal, distribution to the pit is above chamber level pipes w/a speed leveler Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 258 Monomoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): nia Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no adverse conditions exist Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cont.) 268 Monomoy Circ Property Address Centerville City/town State Zip Code Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration n/a 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: n/a Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments lug Subsurface Sewage Disposal System Form C. System Information (cont.) 258 Monomoy Circ, Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Local knowledge puts GW>30' Title 5Template.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r� Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 258 Monomoy Circ. Property Address Centerville City/Town State Zip Code Owner's Name 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. c P� V-gel ` 2--- L 2-3 f a- L S'pCED '�)o � r r Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- No. / t/Z Fee$ 5.0- 0 0,__ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Mi000l *proem Congtruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System kjOXdividual Components Location Address or Lot No.7-5 8 Monomoy Circle Owner's Name,Address and Tel.No. p nnShea Cenev11' 1�e,Mass, 02632 20-C Still Brook Lane Assessors ap/Parce Feeding HI11s,Mass. 01030 Installer's Name,Address,and Tel.No.5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building_gpg No.of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1 000 gallon t;3 of S.A.S. 2-500 gallon chambers. Description of Soil Loamy sand to medium fine sand. Nature of Repairs or Alterations(Answer when applicable) to the existing septic system, oc,rovr..d, 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 issued by t is oard of He Ith. Signed t 1 Date 1 0/3 0/9 7 Application Approved by Date zLe- ©- Application Disapproved for the following reasons Permit No. 9-7-4 z/ Date Issued /0-30-9-7 ——————————————————————————————————————— // ff A / 7'(O Z 9. f Fee $ 5 n _(1�✓ • No. Q - - THE COMMONWEALTH OF MASSACHUSETTS" Entered in computer: ✓ Yes - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,,'MASSACHUSETTS 9i - .2ppYication for Migpogar 6pgtem Congtruction Verna Application fora Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System dividual,Components Location Address or Lot No. `-58 Monomoy Circle Owner's Name,Address and Tel.No. AnnShea Centerville,Mass, 02632 20-C Still Brook Lane Assessor's Map/Parcel Feeding HI11s,Mass. 01030 Installer's Name,Address,and Tel.No 5 0 8-7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son °Inc, J.P.Macomber & Son Inc Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: 4 Dwelling XXNo.of Bedrooms 'A3 Lot Size sq.ft. Garbage Grinder( ) Other -Type of Building . Res No.of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons. Plan Date Number of sheets Revision Date Title C SiZ of Septic Tank Existing 10H gallon tTy PXA S.A.S. 2-500 gallon chambers. Description of Soil Loamy sand to md-dium f ine sand. Nature of Relfairs or Alterations(Answer when applicable) ADDTNC rrLgno n ..R 1 I Q nha b~- to then/existing sepiric system. ; 2 S'�6He oc rcv�.,d, v Date last inspected: Agreement' The u*4ersigned 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 iss ed by t is and of He th. Signed Date 10/3 0/9 7 Application Approved by Date V- O-q Application Disapproved for the following reasons Permit No. 9 7-61 Z Date Issued /0-30-97 ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( XX Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc. at 258 Monomoy Circle Centerville,Mass. 02632 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 T-G 19 dated /0-30-9 7 Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc. The issuance of this permit shall not be construed as a guarantee that the sys Tupcti�qas . Date /d-2/-2 7 Inspector V —A�r�Z�--------------------------- No. Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS M.5pogar *pgtem Congtruction 3dermit Permission is hereby granted to Construct( )Repair(XX)Upgrade( )Abandon( ) Systemlocatedat 258 Monomoy Circle Centerville,Mass. 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 must be completed within three years of the date of this permit. Date: 7 Approved by I f t� t CERTII-,ICATION Or SKE'I'C11 AND APPLICATION MR A DISK, . WORKS CONSTRUCTION PLlt�,Il'1' (WI'I'110U'1' DESIGNED PLANS) 1, Joseph P. Macombe-r--J '..'•=l�t;: certity th:1t the application for disposal works construction permit signed by nlu d--lled __—jgj4,0 jqq concerning the property located at 258 M 1 1 o meets all of the following criteria: t' There are no wetlands within 300 fc.t of the proposed septic system /Tlicrc are no private wells within 1» 1vct of the proposed septic systcrll The observed groundwater t�bJc :s ftct or greater below thu bottolll of 01c Icachillg facility • here is no increase in flow und/01 change in use proposed • There are no variances requested or needed. SIGNED : DATE: J 7 LICE D SEPTIC SYSTEPI INSTALLER IN'1'HE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed s)s;en1. Also if tl:e licensed installer posesses a certified plot plan, this plan should be submilledl. r { I q o JOAO 00 ale s tdAlP AA 1—/�iaT✓ill � �I I TOWN OF BARNSTABLE ✓ LOCATION .Z�o &O Na m o $i C iRCL e SEVACE O �- VI1I;LAGB-..0 P/UTPR V Ie ASSESSOR'S MAP & LOT ; INSTALLER'S NAME&PHONE N0. 0A1 17�333 : . -EPT1C TANK CAPACITY l O O LEACHING FACILITY: (type)?7GU0 Azewc ize) 6`�O NO OF BEDROOMS 3 BLTII:DER OR OWNE Spa' PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: ;'Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet `!`Private Water Supply.Well and Leaching Facility (If any wells exist "`on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist with in.300 feet of leaching facility) Feet Furnished by + . rj �8 Town of Barnstable : Department of Health,Safety, and Environmental Services t�nxsrABM 9 NAM Public Health Division s639• 'OtE0.19 � P.O. Box 534,Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health November 7, 1997 Ann Shea 258 Monomoy Circle Centerville,MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 258 Monomoy Circle, Centerville was inspected on October 20, 1997 by Joseph P. Macomber,Jr.,a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1.995 TITLE 5 (3 10 CMR 15.00)due to the following: • Wastewater and sewage was observed over the invert pipe of the septic tank and leaching pit and over the outlet invert of the septic tank. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (45)forty-five days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground,or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE B ARD OF HEALTH as A. cKean,R.S.,C.H.O. Agent of the Board of Health q\hcalth\dbfi les\title5 i.doc 1 DATE : . 10/20/97 PROPERTY ADDRESS: Ann Shea 258 Monomoy Circle Centerville,Mass . 02632 L On the above date, I Inspected the septic system at the -above address. This system consists of the following: 1 , 1 -1000 ' gallon septic tank. 2 . 1 -1000 gallon precast leaching pit. Based on my Int,c�actlon, I certify the following condltlons: 1 . This is a title five septic system,*' ( 78 Code ) 2 . The septic system is in failure. The waste water and septage is up and over the invert pipe of the septic tank anf leaching pit. The waste water and septage is over the outlet invert of the septic tank. 3 . System must be upgraded to the 95 septic code. -SIG N AT U R G 'I ,c.c�r Name : J . P . Macomber Jr... Company:_J • P_Macoc)ber &- So-rS-_Inc . Address :_ sc�c-66------- ------- CencervilLe `Mass__02632 Phone :___5 �-�3338------- , I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • }OSEPfi P. MACOMBER & SON, INC. T•nkrC�upoolrL4&chf'eds Pump+d L Inst.ilird Town Sowor Connections P.O. Box 60 ' Centerville, MA 02632.0066 775-3338 775-bo12 COMMONWEALTH OF IVIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �E DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617•291.1500 12 1 u ILLI.�,Nf F N ELD ,r Go%cmor C ARGEO PAUL CELLICCI OCI �i re D Li Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI FORg1 CERTIFICATION �oTy Fasrge 199� CP T CF 4C ANN R Property Address: 258 Monomoy Circle Centervill° dress of Owner: 2e_� Date of Inspection: 1 0/1 8/97 (I different) Lance H i 113 Name of Inspector, 1 am a DEP approv sys em rnspectorbpursuanrto Section 15.340 of Title 5 (310 CMR 15.000)Mass . 01 030 Company Name: J.P.Macomber & Son Inc. Mailing Address: gox hh Centerville,Mass . 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I cen-fy that I have personally rnspecled the sewage disposal system at this address and that the iniormation reponee Belo„ is u.,<. and complete as of the time of inspection. The inspection was performed based on my training and experience in the pro_-er i •no.on a maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes eeds Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 4 Date: - In - The System Inspector shall submit a copy of this inspection repon to the Approving Authority within thirty 130) dass of comptetint inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system o--.e1 sr.,!! s_-- the repon to the appropriate regional office of 09 Department of Environmental Protection The original shoulc ae sen: 16 t-re sever^ o and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: A) SYSTEM PASSES: &4L I have not found any information which indicates that the system violates any of the failure criteria as deiined it 3!0 C.VR ! , Any failure criteria not evaluated are indicated below. COMMENTS: Bj SYSTEM CONDITIONALLY PASSES: XM) One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. Tne s,, completion of the replacement or repair, as approved by the Board of Health, will pass. Ind,ute yes, or not determined (Y, N, or ND). Describe basis of determination in all instances. If 'not determ,ned-, N The septic tank is metal, unless the owner or operator has provided the system inspector with a copy ci a Cep,, :-J:r Compliance (artached) indicating that the tank was installed within rwenry (20) years prior to the date of Ire ns:-x o. the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exiiI:ra: on o failure is imminent. The. system will pass inspection if the existing septic tank is replaced with a conform,ng ; as approved by the Board of Health. tr.vi..a 04/15/97) D.q. 1 of to DEP on the Wono Wroe Web. http.r/www magnet state ma uvoep Printeo on Recycieo Paper • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address: 258 MoromoyCircle Centerville,Mass . O-ner: Ann Shea Dare of Inspection: 1 0/18/97 e) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distnbu( on box s due to oro,en Of o s: pipe(s) or due to a broken, seriled or uneven distribution box. The system will pass tnspectjon I Iv to a ?r�•a Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 410 The system required pumping more than four times a year due to broken or obstructed p pets! Tne s>s:em ass inspection if (with approval of the Board of Health) broken pip-e(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: All) Conditions exist which require further evaluation by the Board of Health to order to determine if the system S fj'knz :o D:3:e'7 -..e public health, safety and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUN'CTION'lNC I, A 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) DEZER"1l":S TnaT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: .n A4 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a -a'e: tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public ',ater The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private �a;er ,(f The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 ieet or Tore ,,3_ private water supply well, unless a well water analysts for coliform bacteria and volatile organic compo, r-cs :.;:es the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nwc^ e- s ez,d less man 5 ppm method used to determine distance WI-A (approximation not valid) 3) OTHER tr..•s..a o�/�s/>>r v.9. 2 of 10 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-m PART A CERTIFICATION (continued) Property Address: 258 Monomoy Circle Centervillte Ma O-ner: Ann Shea Date of Inspection: 1 0/1 8/97 D) SYSTEM FAILS: You must indicate e. et "Yes" or '*No' as to each of the following. I have determined that the system violates one or more of the following failure criteria as defined in 310 C--R ' c= Ior this determination is identified below. The Board of Health should be contacted to determine wnat wail c,e neces>ar� t_ :o-' the failure Yes No Backup of sewage Into laciliry Or system component due to an overloaded or clog ed A or cess000 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or c:c'S3E-c ice. cesspool Static liquid level in the stribution box above outlet Invent due to an overloaded or clogged SAS A17— _ LiQuid depth in cpµ4saQl is less than 6" below inven or available volume is less than 112 day ;10- Required pumping more than a times in the last year NOT due to clogged or obstructed pioelsl Number of times pumped Z Any pon,on of the Soil Absorption System, cesspool or privy is below the high ground"ater eie•a:i_- Any portion of a cesspool or privy is within 100 feet of a surface water supply or uibutar to a sit'Iace _:er Any ponion 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 -a.e s o tee, acceptable wale( quality analysis. If the well has been analyzed to be acceptable, anach cooy of welt ar•.a cohlorm bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen E) LARGE SYSTEM FAILS: You must Indicate ether "Yes' or "No" as to each of the following. The following criteria apply to large systems in addition to the criteria above Alv The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system .s a s.3 •• : a .: -�: :_ public health and safety and the environment because one or more of the following conditions exist Yes ,INo /Uj�,4 the system is within 400 feel of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply /fM the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a m.o 7 _ public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater ;rea —e— o 3— rKutrements of )1 a CMR 5.00 and 6.00. Please consult the local regional oHice of the Department for funher niorma;,c- Ir•vp..d 0./1!/97) P•0• ) of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:258 Monomoy Circle Centerville Ma Owner: Ann Shea Date of Inspection: 101 8/97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: yes / No Pumping information was provided by the Q^�n,e,r, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been rece­.ng ,normal now rates during that period. Large volumes of water have not been introduced into the system recen'', as pan of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A 4-1 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,41�luding the Soil Absorption System, have been located on the site _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition o: 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 — The faciliry owner (and occupants, if different from owner) were provided with information on !ne pro, r rra r enanCe c Sub-Surface Disposal System Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) 115.302(3)lb)) lr.vl..d 0�/Is/97) P•9• A of 10 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 258 Monomoy Circle Centerville Ma 0"ner: Ann Shea Date of Inspection: 1 0/1 8/9 7 FLOW CONDITIONS RESIDENTIAL: Design now.,�71,9 R.P.d./bedroom for S.A.S. Number of bedrooms: 17) Number of Current residents:4 Garbage grinder (yes or no):_>� Laundry connected to system (yes or no): i� Seasonal use ryes or no):4e water meter readings, if available (last two (2) year usage (gpo): /(o� _ Sump Pump (yes or no): J — � �'/�ad �f �1?�d �•%,'S/, Last date of occupancy COMMERCIAUINDUSTRIAL• Type of establishment zM1 Design (low: de'!&allons/day Grease trap present (yes or no)&"4 industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Tale S system: (yes or no) '!LJ' Water meter readings, if available /f4 yA Lasi date of occupancy OTHER: (Descr,be) Las( date of occupancy' GENERAL INFORMATION PUMPING ECORDS an source of information: System pumpeJ as pan of merlon: (yes or no)_9- y )975 If yes, volume pumped: �J_�J g�a�o�� /� �D�i�ar Reason for pumping �US/ v1 �' TYPE OF YSTEM Septic absorption system ­d.0 Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Dher APPROXIMATE AGE of all components, date installed (if known) and source of information: / C Sewage odors detected when arriving a( the site: (yes or no) je} (r•v1••d 0�/75/97) P.9. 5 of 10 • SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORm PART C SYSTEM INFORMATION (continued) Pioperi� Address: 258 Monomoy Circle Centerville Ma owner: Ann shea Dale of Inspection: 1018/97 BUILDINC SEWER: ,Locale on site plan) Depin oelo- grade grit material of consirunton cast on 40 P C other (explain) r - D stance irom private water supply well or suAton line 41 !•! D,ameter _ Co ments tcond�l,on of Io1nis, vents g, evidence of leakage, etc.)n SEPTIC TANK:1ewo.'A w-5 route on site plant P� Depth below grade. nnatenal of construcl,on. jeeoncrete _metal _Fiberglass _Polyethylene _other(explain) II tank is metal. list/age,(!/_ Is age confirmed by CenlLcate of Compliance 4/4(Yes/No) D.mens'ons I �b 11�04 / %�G � '` Sludge depin. Z15) Distance from top 91 sludge to bosom of outlet tee or baffler Scum thickness _d D,siance irom top of scum to top of outlet tee or baffle:�_ D.stance from oonom of scum to bonom of outlet tee or affle -iow dimens,ons were determined. Comments rrecommendalron for pumping, cpndo 0 of Inlet and outlet tees or baffles, depth of liquid level in relation to ovJet invel s;r• ntegr 1, evidence of leakage, ic ) fi d.= /� / � 9 J CREASE TRAP (locate on site plan) Depth below grade m.atenal of cot)strucswnitEconcreteN�metaW( fiberglass,,�olyethylenert/�other(expta n) D,mens,ons: Scum thickness. Distance from top of scum to top of outlet tee or battle: .eI4 D,stance from oonom of�scum to bonom of outlet tee or baffler Dale of Iasi pumping Comments trecommendatidn for pumping, condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet Inver,. ,ntegriry, evidence of leakage, etc 1 , ir.vs..a F.9• c of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:258 Monomoy Circle Centrville Owner: Ann Shea Date of Inspection: 1 01 8/97 I TIGHT OR HOLDING TANK(Tank must be pumped prior to, or it time, of inspection) (locate on site plan) Depth below grade )e Material of construn�ctionM concrete-metalA-$,berglass�Pol�,ethylenewAther(explain) AIM AM Dimensions: ,e)W Capacity: gallons Design flow: gallons/day Alarm level! ;DW_ Alarm in working ordea(/ es"Oh No Date of previous pumping: 1VX Comment (condition of inlet tee, condition of alarm and float switches, etc ) DISTRIBUTION BOX:JL e- tlocate on s-te plan) Depth o: liquid level above outlet invert: 40L Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:2hoop- (locate on site plan) Pumps n ,.orking order: (Yes or No) Alarms �n working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) - ZOWz P.g. 7 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address258 Monomoy Circle Centerville Ma Owner: Ann Shea Date of Inspection: 1 O/1 8/97 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: l/ leaching galleries, number:? leachingarenches, number,length.-- j-- leaching fields, number, dim sions: lJ overflow cesspool, number: Alternative system: Name of Technology Comments (note condition of soil, signs of h�dr ulic,failur , level of ponding condition of vegetation, etc.) f l CESSPOOLS:4XVC (locate on site plan) Number and configuration: Depth-(op of liquid to inlet invert: Depth of solids layer: i( Depth of scum layer: 424 -t— Dimensions of cesspool, AI Materials of construction: 44 indication of groundwater: P14 inflow (cesspool must be pumped as pan of inspection) r Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIM`l (locale on site plan) Materials of constructr n 145"WIT Dimensions: 'lox Depth of solids. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 79 2E2 , (r.vs..d 01/75/97) Y.9. 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address:258 Monomoy Circle Centerville Ma owner: Ann Shea Date or Inspection: 1 0/1 8/9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: "dude I.es to at least rwo permanent references landmarks or benchmarks locate all wells within IN* (locate where public water supply comes into house) a5 � (1'�oncmoy C�rc�l� 35 I � (1-1-0 04/73/17) P•p• 9 of 10 SUBSURFACE SEwACE DISP• SYSTEM INSPECTION FORM SYSTEM INFOI. :10,N (continued) Properly Address:258 Monomoy Circle Centerville Ma Dw^er Ann Shea Date of Inspection: 1 0/1 QV/9,7 Iqr f Depth to Croundwate Feet Please nd-cate all the methods used to determine High CroundwaW OL- aeon: _ Obtained from Design Plans on record -OZObserval-on of Site (Abuning properly, observation hole, basen+crst'simp etc.) _ZDeterm,ne It from local conditions Check wdh local Board of health _ Check FEMA Maps Check pumping records Check local e•cavators, installers Use USCS Data Oesc,oe n your own words hdw you established the High Croundw.ner'Elevation. (Must be completed) Used Cape Cod Commission Map. September 95 Water Table Contours Public Water Supply Wellhead Protection Ares ..r Ir••i..e Or/75/9'11 D•5• oc 30 i r r.nr+-n,rr-�-.mrnrrm rs-r*n.rnr.rrn:•.�.++•v.r:+r•�*rmn is--.v r•�sr.nT mv+rn-cm�r..-rr+-,c-T- TOWN OF Barnstable BOARD OF HEALTH SUIISURFACF 9F.WA(;E DISPOSAL SYSTEM INSI'FCTION FORM - PART D - CERTIFICATION �_ �. - -�-+�.r,r+.•n:m rzrr.srrsrrrr.•..-•.�^„rr.e-••rnvr-r..n*Svrn art mnn•�mr+.rrrm+.,+..-rr- r._. -. 1 r T -TYPE OR PRINT CUARL1'- PIlOPERTY INSPECTED STREET ADDRESS 258 Monoy Circle Centerville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Ann Shea PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & Sion, Inc . COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 S t r 9 e t Town or City St,t. t!P COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : Systevi PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe. environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of is form . System FAILED* The inspection which I have con�ucted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signatur e Date One copy of this cert.ification must be provided to the OWNER , the BUYER ( Where applicable ) and the DOARD OF II EAL'11I. • If the inspection FAILED , the owner or " perator shall upgrade the eyotern wi VA) in one year of the date of the inspection , unless allowed or { require otherwise as provided in 310 ChIR 15 . 305 . ' partd . doc W � r V 1 ti S byV 31�l TCO COMMON Ei ALTH OF MA.SSACHUSETTS DEPARTA4ENT OF ENVIRONNIENTAL PROTECTION BE IT KNOWN THAT A. Joseph P. Macomber, Jr. Has satisfied the Department's quali�icatlus as required and is hereby authorized to use the title CERT { { D TITLES SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws . Issued by The Department of Environmental Protection- 1 u nc 3. t S — Acting Oarcctor of Utc O t11r"t W21ct Pollution Control S AL � r � No . .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q W,N................... ...................OF.... +. ...t.._._. ........................ loAppliration for Mipmal Morkii Tomitrudivit ramit 4. 0 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at - .............` •-5'--...Aftivi .....C 1 W ..................................... `r --Locatigx�-Address or Lot No. .... ... ........••--••--- -----_. _.. _........: �!$�. _:..-rpm ._.�. - ........ Owner Addr ss Installer Address � d Type of Building Size Lot_1� ...Sq. feet aDwelling—No. of Bedrooms........ ____________________________Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fiat res ............................................................... Design Flow..........__j .........................gallons per person per day. Total daily flow_.._._::: .__.__._._.______gallons. WSeptic Tank—Liquid capacity/__gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ____ Width____ .o�_� °,tal Length____________________ Total leaching area....................sq. ft. Seepage Pit Diameter_ 9______ _.. /Dep"fh belo, ililet____________________ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank '~ Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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_______________________. r A O Description of SpilIA v �1 -=.Q.'y !!_. .._.._.... x �g�'h"� U -------------------- y ----- -- --- 1;_ f. '._.._...... 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 u clersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuedsb th board of health. e� , / Sia -•--• -............ -......................................................... ......... Va Application Approved By.........f::�. ..... .... .... ....!.1 �ff(.. �� c• - g� �� ............................................ate Application Disapproved for the following reasons_____________•-•-_-_-- ____-__--•----_ ...............•------.....-•-------...------•---•------•--._.._..---------------------•-----•--...-.-------•-------..._•-----------•••--••-••-•••- -�Date Permit No.......................................................... Issued...... ............................................... Date No......................... FRE.............................. THE COMMONWEALTH OF MASSACHUSETTS 7� BOARD OF HEALTH _4 Appliration f v r Mspaoa.i Works Towitrudion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: r Locat' Address- or Lot No. Owner f}�.,y6+l� Add ss !! / ... ^4 .................. ..................... Installer Address aysr. dType of Building J4,' Size Lot. . . .O". ...Sq. feet aDwelling—No. of Bedrooms........ ----------------------------Expansion Attic ( ) Garbage Grinder ( ) p� Other—Type of Building ..:......................... No. of persons............................ Showers ( ) — Cafeteria ( ) f4 Other fixtures ...................................................... W Design Flow............ti6'- ----------------------gallons per person per day. Total daily flow__..__.-.-------------gallons. � Septic Tank—Liquid capacity !..gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................. Width--- .__ �al Length.................... Total leaching area....................sq. ft. x axeSeepage Pit No. . . ___ _ -- Total leaching area..................sq. ft. ___. Drarneter _____. Z Other Distribution box ( ) Dosing tank ( ) 0 - CA . e 1 e o inlet.................. Percolation Test Results Performed by..................:......................... _......_._. Date........................................ aTest Pit No. 1................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........................ -I t ......................w -- •-• --••.• -• - r Descri�tion of Soil °,'� -- ---id �„ '".t ! ............. ---------------•--- ...-------- � v UNature of Repairs or Alterations—Answer when applicable.--__............................................................................:.............. i -•--••--•----••.............•---•-•--•--......•--.......---•••----- 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 u ersigned further agrees notxto,place the system in operation until a Certificate of Compliance has been issue th oard of h lth. Sig a ... Lt.,y ._ ..._.__.. ... ...................... ........ . y at Application Approved By------ r ' ----------------------- . . • ID ate Application Disapproved for the following.reasons,:'--- ................- --•--•------•-----•--------------------• .....................................--------- ...-------•-----•----------•----•-•-------------••------ ------------------------.---•----------------•-----••-•--•-•--•......--•-•-•-------...... Date PermitNo......................................... Issued...................Date................................ Date � • x +Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........OF:.:... rOOO4++ r :.,.............. G.rifiratr laf THI T ERT Y, That the Individual Sewage Disposal System constructed ( or Repaired ( ) r -4�" .._ ......................... ............... •„ Instal +. f has been installed in accordance with4ieprovisions of Article XI of The State Sanitary Code as described in the _�_ ` application for Disposal Works Construction Permit No.-..........�'� X- -•---• dated....�� �-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................... = .......... Inspector..........._........................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT t l..........OF..........' r «.*C..c . .. No.... �.. FEE... .(,,,,,,,,_,,,,,,- .�.� yt y. Permission is ereby granted._:. .. _.... 4!"x..9--------------------------------------•--•--•-•-•-•-----......-•----•--........... . to Construe or Repai ) an Individual S age ispos Sy at No.x+. .... .. A..... ,... .._.... .. Street , as shown on the application for Disposal Works Construction P it N.'..._..... Dated___f;Z.wr _7 ...... .................................. .�. 7. oard of Healt A� DATE..J'.--••------- ---•-----...........•----•----------•-------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS .. .,r r RO IQ r fiy.� .. ......w.M....»v....a..�...w>.v�:•++.w�..w.e.......-.n.•ar.,+:+t�wnw..�.w.wa�ewn�w• ..w,n,.mrw+>mww+rwwrw�cmvm,oiw*a..sw.m,,.o:•ar_.++w!'.q�....,+�w++.w++..c.bvw...«�w.w+r.,..a,rw»,w.�»-w+.....«.,...r_....»..+„+.y.,..o.-.M�........�,........a.+..+.......�.. i I j r i V I t I t�f' :J nc. ;€�.'': • k. Jed. 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