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HomeMy WebLinkAbout0066 OUTPOST LANE - Health 66 OUTPOST LANE, CENTERVILLE A= 172 116 Sl/ll 2J�QEcvc�o�o2.. fiff UPC 12534 No.2�OR `�srco '� HASTINGS,MN t � • COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICEOF ENVIRONMENTAL AFFAIRS - h Q DEPARTMENT OF ENVIRONMENTAL PROTECTION Y f f V / 1 v/to / • 0� //N TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Sr 3�/3 � Property Address: Cv (o f�� T S�- L,/v c o� G 3�L _l ✓4 a rf// n-I cis rill Owner's Name: o be,-4- y e > Owner's Address: c ,t/� o, w Date of Inspection: d- 4S p � Name of Inspector•� ?I)G1rl _ �O Please print) //i %Ao rn Company Name: CWVl — LAG Aj Mailing Address:—PO b X /d 9 Q 02 6 qd, Telephone Number: — C/ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: I� Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �`� Date: /oZ L Dom'_ 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CIERTIFICATION(continued) Property Address: ry of 6 3 a-- Owner: tA vT Date of Inspection: /1- 7A95. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. r m Passes: ave 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: VB S stem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titles G Tnannntinn 17^ m / 2 � T cnnnn Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: vJ- '40OW- h rv,- D�G3.L Owner: n p Date of Inspection: / as- C. Further Evaluation is Required by the Board of Health: ,1/2 Conditions exist which require fiuther evaluation by the Board of Health in order to d is failing to protect public health,safety or the environment. determine if the system 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Titles C (n cnortinn �nrm All 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) t Property Address: L- 14 ram.' Oa63� Owner: CA r 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/ 13ackup 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 E �elogged SAS or cesspool _[/ St tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _ !esspool quid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow Re uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped _ g�ty portion of the SAS,cesspool or privy is below high ground water elevation. _ An portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface �+ater supply. any portion of a cesspool or privy is within a Zone 1 of a public well. 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. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) es 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 ne 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 G incnontinn Fn.rn Ali ci,)nnn 4 Page 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / �CHECKLIST Property Address: 0 7 /'O /— Owner: S vl#? Date of Inspection: oZ p Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o — 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? L, Has 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? v — Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no / _ ./Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue a is unacceptable)[310 CMR 15.3 02 3 b approximation of distance i Titlo G inenoi.tinn Fnrm A/i cnnnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7' O 4- G Owner: SDI n r Date of Inspection: ;k Qj FLO C NDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): .� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: O Does residence have a garbage grinder(yes or no): /(IV Is laundry on a separate sewage system ye or no);� [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): es Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):ZKV Last date of occupancy: /Y COMMERCIALANDUSTRLAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Oo Was system pumped as part of the inspection(yes or no):_� If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP F 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: �/T �, ✓� s L-- Were sewage odors detected when arriving at the site(yes or no): Title f Tncnrartinn Aran 4/1 annnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: Y vi T 0 L owner:ScA I r_j h-0 if-e4 Date of Inspection:7�2 42�,a/� BUILDING SEWER(locate on site plan) I/ Depth below grade: Materials of construction:_ ast iron -0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(1`� ocate on site plan) Depth below grade: / Material of construction:— ooncrete_metal_fiberglass___polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: `j X Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 02 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: How were dimensions determined: Aa e, v/ c 6— Comments(on pumping recommendations,inlet and outlet tee r baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,a .) _ rgo-Y, ✓► i9PmC-e a 9:;i 1 t �l•-art, / G, G►✓+ „ /✓! Ocn r 0P1 GREASE TRAP:&(11ccate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): I Titlo G Incnartinn Fnrm�n v�nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C I Pili� ©oL6 >-L Owner: v1✓► ,� Date of Inspection: /ot TIGHT or HOLDING TANK tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: 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: ✓1IM/-7 4 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or >t of box,etc.). , PUMP CHAMBER: locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): TitIA G incnArtinn 1 nrm rill ci�nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) f Property Address: (� K/ A T i"O S� y Owner: r Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: k l �eac. )a/e,number: leachingchambers number: leaching galleries,number: L✓ leaching trenches,number,length: --II leaching fields,number,dimensions: 5T0 overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soi, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): ,-c- y'-e i CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) t Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): t f R f 1 4- C Title S fncnartinn Rnrm lii »nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66, L- Itl Owner: n /� 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. V 11-3 d� , 3LI 3 � ' Titia C i--,t;— P,— A/1 CIinnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1t'� O,f 4 �` ,••ter ��G7v� Owner: v) r Date of Inspection: AdOj SITE EXAM Slope Surface water ' I Check cellar Shallow wells 03 Estimated depth to ground water l feet O Please indicate(check)all methods used to determine the high ground water elevation: Obtain d from system design plans on record-If checked,date of design plan reviewed: Cilyfierved site(abutting property/observation hole within 150 a of SAS) Checked with local Board of Health-explain: ct Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: iF You must describe hppw yo established th high gr�o}u�nd water a evation: Grote„ c' a ►rf �� c4��oh S 7 i�9000 k 0O j ti 0 006 � l Cn Q,���0 , �f / 9- 9 Titles Iq Tnenontinn 17-(./i C/in 11 nn ( � 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 66 Out Post Ln Centerville owner's name Leona Kelly Date of Inspection 8-1 -95 PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for 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. / As built plans have been obtained and examined. Note if they are not available with N/A. V The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. , l/ All system components, excluding the SAS, have been located on the site. 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. I/ The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents it/ garbage grinder, yes or no laundry connected to system, yes or no i seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and/ source of 1lnformation: y o^ So Tkc ✓ System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Types of system t/ 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: �.6 'Q 04 Sewage odors detected when arriving at the site, yes or no 1 1 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade:_ material of construction: ' concrete metal FRP other(explain) dimensions: 13 sludge depth distance from top of sludge to bottom of outlet tee or baffle p 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendati ns for repairs, etc. ) DISTRIBUTION BOX: v (locate on site plan) C� depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) ..A=Zpumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for mainte ance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : I/ (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 and number l® 1 ) d b 76 e leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, reco endations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 1 Gl� L `t r DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: 1 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped 7 Septic tank is metal .7 cracked. structurally unsound.? substantial infiltration? substantial exfiltration? tank failure imminent? / Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? 4Zwithin 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? Within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION I -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 66 OtLf Post Ln Centervitl6E ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Leona Kelly ---....- - --- --- --- — — - — --- - .......... PART D - CERTIFICATION NAME OF INSPECTOR W.E. Robinson Sr COMPANY NAME W.E. Robisnon Septic Service COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632 Street Town or City State $IP COMPANY TELEPHONE. ( 508 ) 775- 8776 FAX 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 . Chec one : System PASSED The inspection which I have conducted has not found any information whic1h 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 which 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 5--L— �-6 One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator 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