HomeMy WebLinkAbout0372 OLD CRAIGVILLE ROAD - Health 372 Old Craigville Road
1 = 247-021 Centerville
A
UPC 17534
N2.2-15 LCOR W—
KAISTINGS. �s,.ros�
UN
. No. r� Fee "
3 0p lryr) THE COMMONWEALTH OF MASSACHUSETTS
34 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Miopooal *r5tem Construction 3permit
k;
'* Application is hereby made for a Permit to Construct( )or RepairXXX)Xan On-site Sewage Disposal System at:
+ Location Address or Lot No.3 6 4 Old C r a i g v i l l e Owner's Name,Address and Tel.No. 61 7—7 2 9—8 2 8 6
k oad, �jegt Hyannisport,Mass.02672 Joseph Donlon 12 Cranston Road
ssessor s ap/Parcel inchester,Mass. 01890
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. Lx
P.Macomber & Son Inc.
Box 66 Centerville Mass. 026 2 66 Centerville Mass. 02632
Type of Building:
Dwelling X)(No.of Bedrooms 3 Garbage Grinder(Nq
Other Type of Building RES No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 0 gallons per day. Calculated daily flow 3 X 110=3 3 0 gallons.
Plan Date 10/9/9 6 Number of sheets Revision Date
Title
Description of Soil Loamy sand to nand & gravel to medium i n , sand
Nature of Repairs or Alterations(Answer when applicable) Relocating pit that is in t h e
neighbors yard. / ,
Date last inspected: 10�/ /96
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 iss d by this oar ofalth.
Signed i ;''��� A. Date 1 0/9/9 6
Application Approved by y Date /0
Application Disapproved for the following reasons
Permit No. Date Issued �����
a
_-• _
No. Fee� � j
M. s (' THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS i
ZIppYtcatton for Mtgpogal *pgtem Congtructton Permit
Application is hereby made for'a;Permit to Construct( )or RepairXX)0)4n On-site Sewage Disposal System at:
Location Address or Lot No. 364 Old Craigville Owner's Name,Address and Tel.No. 617-729-8286
Alqil.4sNglplEelHyanifisport,Mass.02672 ' Joseph Donlon 12 Cranston Road
Winchester Mass. 01890
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 8_7 7 5—3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc:
Box 66 Genterville.Mass. 02632 Box 66 Gentervil e Ma s . 02632
Type of Building:
Dwelling X)No.of Bedrooms 3 Garbage Grinder(NQ
Other Type of Building RES No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day: Calculated daily flow 1 10=330 gallons.
Plan Date in/A/4 h Number of sheets Revision Date
Title 1"
i. � `
F Descriptioq'of Soil _Loamy esa e n d t o sin.*'tip X sr a y e l to Ta ri�i r i m fine s a n di
!/ N,
Nature of Repairs or Alterations(Answer when applicable) Relocating pit that is din the
' ahbnrs va,rd.
-
'Ir; Date last inspected: ai n i i
96
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 oazd,' f He alth.
Signed Date 10/9/96
Application Approved by Date
Application Disapproved for the following reasons
- Permit No. Z y ` Date Issued /0�0''"7/��'
F •
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
t
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced TX)on
by ..y Installer_ aP 14nanmbev. & CoTn Inc
at q4j _ n_^ _ c9a T t + t _ • n -m has been constructed in accordance
with the provisions of Titlet and the for Disposal System Construc 4ermit No. L �� dated
Date o�,� .� Inspecto�
Y r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
f -------- ------------------------------
No. Y_I. �" /� Fee $40-.,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS
Mtgpogar *pgtem Congtructton Permit
Permission is hereby granted to j,P,Ma n n m h A r R. S n n T n n.
to construct( )repair(KX)an On-site Sewage System located at No.# 364 01_d Gra.i av111_a Road
West Hy tinl'aportd,Mesas ,
Ij Street
h and as described in the above Application for Disposal System Construction Permit.
. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
Date: /�� /�� � Approved bK_ L_Z'c" :�_
i Board of Health
I
CER'FIFICA'I'ION Or SKET'CII AND AI'PLICA"PION F012 A DISPOSAL
WORKS CONSTRUCTION PERNIrr {WITHOUT DESIGNED PLANSI
I Joseph P.Maeomber Jr.__, li�:rcby certify that the application for disposal works
construction perrtut signed by nee dated -1Z A06- , concerning the
prjperty located 064 Old Craigville Road West meets all of the
Hyannisport,Mass .
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 i'cet of the proposed septic system
• The observed groundwater table is A feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNE — DATE: 10/10/96
LICE SEPTIC SYSTEM INSTALLER 1N THE T0WN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses.a certified plot plan,
this plan should be submitted].
TOWN OF BARNSTABLE
LOCATION--;404PO L d C R ,4 r G VB L L e R06 SEWAGE #76 v S/
VILLAGE ASSESSOR'S MAP& LOT2 L
INSTALLER'S NAME&PHONE NO. /1/! G ®M g e!L Soy 7 qs"-333�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /O�' (size) °®d Z)
NO.OF BEDROOMS
BUILDER OR OWNER PERMIT DATE: /a''',O ` ;p 4� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by &,W
ivvoo�-
(f�i v
7
Oj
, 9
�t
I i
ASSUSSOFIS MAP NO:
%
4 U
N �
Commonwealth of Massachusetts
Executive Office of Environmental Affairs NOV -
Department of ,� isss �
Environmental Protection WUllam F.Waldo p` Trudyu Cori
aovemw p 6
Arpoo Paul Celiucci Da .Struhs
LL Gawma C*nuNubner
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
/ PART A
7 CERTIFICATION
Property Address: Old Craigville Road West AddreasofOwner. 12 Cranston Road
Date ofInspectlon: 10/9/96 Hyannisport.MAIfdifferent) Winchester,Mass .
Name of Inspector.. Joseph P.Macomber:.'Jr. 01890
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
— Fay �y��us�,,� G '
Inspector's Signature: Date:
The System Inspector a submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner And copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
4& I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not)
A4a[e. The septic tank is metal,cra:ked,structurally unsound, shows substantial infiltration or enfiltration,.or tank failure is
imminPat. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) I
� t
}
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddresx364 Old Craigville Road West Hyannisport,Mass .
Owner. Joseph Donlon
Date of Inspeotionl 0/9/9 6
B)SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or ho static water level observed in the distribution boa is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution boa. The system will pass inspection if(with approval of the Board of
Hsalt :
broken pipe(#)are replaced
obstruction is removed
distribution box is levelled or replaced
r The system required pumping more than four times a year due to broken or obstructed pipe(#). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH;
A2h Conditions exist which require further evaluation by the Board of Health in order to determine it the system is failing ip protect the
Public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEN n
d Cesspool or privy is within 60 feet of a surface water
�a Cesspool or privy i# within 60 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINEg THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT;
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tr�utary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
410 The system has a septic tank and soil absorption system and is within 60 feet of a private water supply wall•
The system has a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private water
supply wQA unless a wall water analysis for coliform tact U and volatile organic compounds indicates that the wail is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm.
9) OTHER
The system has a 61x8l block cesspool with a 1000 gallon
leaching Di 1 3a an over ow esspoo 1
as a septic. tank.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
PropertyAddrese: 364 Old Craigville Road West Hyanni sport,Mass .
Owner. Joseph Donlon
Date of Inspection:1 0/9/9 6
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
�D Discharge or ponding of eMuent to the surface c,f the ground or nufam waters due to an overloaded or clogged SAS or
cesspool. 0
Al2V(�- 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of tunes pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
(� Any portion of a cesspool or privy is within a Zone I of a public well.
&D Any portion of a cesspool or privy is within 60 feet of a private water supply well.
�d Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
/ The following criteria apply to large systems in addition to the criteria above:
A /� The system serves a facility with a design flow of 10,000 gpd or greater(L Lrp System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
&T 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
—AA the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for Nrther information..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 364 Old Craigville �oad West Hyanni sport,Mass .
Owner: Joseph Donlon
Date of Inspeotion:10/9/9 6 •
Check if the following have been done:
,Pumping information was requested of the owner,occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
4A As built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
, All system components,-4e uding the Soil Absorption System, have been located on the site.
A-W,'t-The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
, The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
surface Disposal System.
(revised 11/03/95) 4
`5
SUBSURFACE; SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddirs:: 364 Old Craigville Road West Hyannisport,Mass .
Owner. Joseph Donlon
Date of IanPoutiQL:; 1 0/9/96
FLOW CONDITIONS
RES I D ENTIAI:
Design IIAw: pny � .
Number of bedrooms:
Number of current residenta:-9-
Garbage grinder(yes or no):•—/l]
Laundry connected to or nq):Ao
Seasonal use (yes or
Water meter readinss, if avaiLible: C� Z'!6� -;;
��( =
2"
l <7 Z = 4 YO j -
Last date of occupancy raw
COM-4F-RCIAL/INDU9TRIAL-
Type of establishment: ,04
Dasid^n Dow:-Azijons/day
Grease trap pre"ot: (,yea or no)&4
Industrial Wane Holding Tank present: (yes or no),"
Non-sanitary wasw discharged to the Title 5 system: fives or no)-f01
Water meter readings, if available:)
Last date of occupancy:—/A
OTIIER: (Describe)
Last date of occupancy: /U
GENE1LlL INFORMATION
PUMPING,R,ECOILS and source of irdoriration:
0 4( Vti 0tVA��atblcz G e t e)c rr kc,
System pumped pan inspection. (ye, or u0)A26
If yea, volume puraped:
Reason for pumping; 274
TYPE OF SYSTE.'.I
Septic tauk/distribution box/sod absorption r)stem
9irple cv::.l;,c1 .
Ovrr'11ow be.�,;� LOdc')Ql���v �lCJ4C�A?^j p�
Privy l
Shred system (yes or no) (if yes, attach prev41Vious inspection records, if any)
Ocher (ezpL..in)
At PROXIMATE AGE of ull components, date u:.atullal (if krtiown) and source of information:
Qw m.on rvA-
.J...,.......1 ...L,.� .._.___ .
'..',.'SSURFACE SDYACE UISPOSAL SYSTEM INSPECTION FORM
PART C. •
SYSTEM INFOYDAATION (continued)
Property Address: 364 Old Craigville Road West Hyannisport,Mass .
Owner: Joseph Donlon
Date of Inspection) 0/9/96
SEPTIC TANK:,JNV_ '
(locate on site plan)
Depth below grade: N
Material of construction 4oncrete _metal _FRP __olhvf(vxplain)
Dimensions:
AM
Sludge depth:_ 3`�•._— — — T—
Distance from top of sludge to bottom of outlet tee or bJilli: /1�/9_
Scum thickness:_ _ M
Distance from top of scum to top of outlet tee or baffle:
V
Distance from bottom of scum to bottom of outlet tee or b�iilc.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle,, depth of liquid IPvel in relation to outlet invert, structural
�ri(y, evidence of leakage, etc.)
�F C Tip t s ,va r ',? 7--
GREASE TRAP.AeNf,
(locate on site plan)
Depth below grade:,,
Material of constn iionMoncrete _metal _FRP
Dimen;ions•
Scum thickness:.Distance from from top ut scum to top of outlet tee or baffle:_4V
Distance from bottom of r„m t,, bottom of oullet u t or u5n" )&
Comments:
(recommendation for pumping, condi—ri of inlet and outlet tees ur bahlus, depth of liquid level in relation to outlet invert, structural
int.e rity, evidence of leakage, ett,�_p
O 4,r'e.'1 '45'r-TrC'E/4 SQ `
4'
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PrcpervAddresa: 364 Old Craigville Road West Hyannisport,Mass .
Owner. Joseph Donlon
Date of Inspection:l0/9/9 6
TIGHT OR HOLDING TANK:dj7W1°
(locate on site plan) •
Depth below grader
Material of construction:1/jconcrete_metal_FRP_other(ezplain)
AIR
Dimensions: AM
Capacitygallons
Design slow: ons/day
Alarm level:
Comments:
(` fir n of inlet edition of a a larm nd floats tc ,etc.)
/s ,U�r °
DISTRIBUTION BOX:A��
(locate on site plan)
Depth of liquid level above outlet invert:1
Comments:
(not 9level distribution ' equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
GTr1 GI 7541�b D bC > S nzo 7 7.
PUMP CHAMBER:/Vj/ye—
(locate on site plan)
Pumps in working grder:(yes or no)-&24-
Comments:
(notAU �n of Rump chamb ,condition of pumps and ap ces,etc.)
1N //h Y4 s�N is
(revised 11/03/95)
.SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 1•vl-"A
PART C
SYSTEM INFORMATION (000tinued)
Pvjp.rt, .. . . . . 364 Old Craigville Road West Hyanni sport,Mass .
Owner. Joseph Donlon
Date of 1 0/9/96
SOIL ABSORPTION SYSTEM (8A9): t IW ' � ~`�� A�
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
•
If not determined to be present, explain:
leaching pits, number:
leaching chambers, number
leaching galleries, number: 75
leaching tronchos, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:n
Comments: (note condition of soil, Big" of hydraulic failure, level of poa&ag, condition of vegetatioa,,etc.)
Loamy sand to medium sand;No signs of Hydraulic failure ; o signs o
ponding;All vegetation is normal.
Lan ohi ngp i t. mliRt be fillad in or relonated. Pit is on neighbors yard.
CESSPOOL4:
(locate on site plan)
Number and configuration: I _
Depth-top of liquid to inlej Overt:
Depth of solids layer:
Depth of scum layer:
Dimensions of oca,pa01: 0 _
materials of cotutruct:on: ' e
Indication of grouadwaWr: 'S _
inflow(ooaspool must be pumped as part of inspecti )_1f��
Comments: (note condition of soil, signs of hydraulic failuro, level of ponding, condition of vegetation, etc.)
Same as above
PRIVY: hoe-
(locate on site plan) n
Materials of oo n• o Dimensions: 1/A
Depth of solids,
Co ts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
6J:�jUR.FACE SEWAGE DISPOSAL SYSTEM INSPECTION ,PUItA
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L :SPOSAL SYSTEM:
include ties to at least two permanent references landmarks. or benchmarks
locate all wells within 100 '
• Centerville Osterville Marstons Mills
Water Company
428-6691
2
y 04d C'v 19 v,
DEPTH TO GROUNDWATER
161 +, depth to groundwater
m th,od of determinetion or approximation:
ins tilledd-''`�stks• -a't 1 F dad' Cfva' v�ille . Rga permit # 80-420
�...... r' v e oa ermi
- jai • . °e oa germ
No water encountered at 121
Jos ��r
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ton of Water Pollution Control
Ni
.._..._..... ..... .—.. ...�..—.—.....T.T.—.T_...- ._...
TOWN OF Barnstable BOARD OF HEALTH
SUHSURFACF SFWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION Ay1
'' �!•.•-•••-r••.-•.:•--••-^--.r.—rr.:•r:.;r.-r.r...�--••�••••-:.--c...•..... .-�s+..:-rr.�-.�rsrr-:.�•-r..rsr^srr.--r--=sxrs.-s-.r.•rarrr.-rt•—rrcTrrr.•.—rrr r- .-. A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 364 Old Craigville Road West Hyanni sport,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' S NAME Joseph Donlon
PAIZT D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & S<m' Inc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State tip
COMPANY TELEPHONE ( ) - FAX ( )
r _ _. __508 775 3338 508 790 1578
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 :
XXXXXXXXXXSystem PASSED Conditionally
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or, the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection wtiic), I have conducted 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 Signature Date 10/9/96
One copy of this c rt.ification must be provided to the OWNER, the BUYER
( Where applicable ) and the BOARD OF 11RAL711.
* If the inspection FAILED, the owner or•" 'Pierator shall upgrade ' the system
within one year of the date of the inspection , unless allowed or required
otherwise . as provided in 310 CMR 15 . 305 .
partd .doc