HomeMy WebLinkAbout0314 PHINNEY'S LANE - Health (2) E
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D ATE:7/26/0
PROPERTY ADDRESS: 314 Phinneys Lane
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Centerville , Mass .
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02632
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On the above date, I inspected the septic system at the above ad KEMVED
This system consists of the following:
1 . 4-5 ' X7 ' Bloc cesspools . Al If, 6 1002
2 . This is a split system. TOWN OFBARNSTABLE
3 . See page 10 HEALTH DEPT.
Based on my inspection, I certify the following conditions:
4 . /This is not a title five septic system.
5 . This is a sewage system.
6 . The sewage system is in proper working order at the present time .
7 . Pumped #3 cesspools at time of inspection . No signs of water
intrusion .
8 . The three remaining cesspools are dry .
SIGNATUR
Name: J.-P. -Macomber-Jr.
Co nip any:Josefh P._ Macomber & Son, Inc.
Address: Box 66
--------------------
Cen_t_erv-ille,_L1.d-_Q2632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 314 Phinneys Lane
stervi e , ass .
Owner's Name: Steve Heckler
Owner's Address: 184 South Main Street
Suffield CT. 06078
Date of Inspection: 7/2 6/0 2
Name of Inspector: (please print) Joseph P. Macomber Jr.
Company Name: Joseph P_ Maromher & Son, Inc.
Mailing Address: Rnx Fr,
('Pnt-PrVl I I P Mai 02632-0066
Telephone Number508-775-3338
CERTIFICATION STATEMENT
I certify that 1 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
Opproved system inspector pursuant to
Section 15.340 of Title 5 (310 CMR 15.000). The system:
�i✓ Passes
_ Conditional]\, Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature Date:
The system inspector shal ubmit 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 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:314 Phinneys Lane
en ervi e , a
Owner: Steve Heckler
Date of Inspection: 7 2 6 0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes•
l�1L have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or in 31 exist. ny failure criteria not evaluated are indicated below.
Comments:
The sewage system is in proper working order at the
present time .
B. System Conditionally Passes:
�b 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.
Answe
r ye
s,Y 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.
,NDt9eexpllain:
'observation of sewage backup or break out or high static water level in the istribution bo ue 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
obstruct
ion is removed
ND explain:
2
Page 3 of I I
OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propem Address:314 Phinneys Lane
Centerville , Mass .
Owner Steve Heckler
Date of Inspection: 7/26/02
C. Further Evaluation is Required by the Board of Health:
d Conditions exist which requve funher evaluation by the Board of Health in order to determine if the system
s falling to protect public health, safety or the environment.
I. System Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
syssttem is not functioning in a manner wbich will protect public health, safety and the environment.
AV Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh
' System µill 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:
IVA The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supple or rributary to a surface water supply.
a The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple
0,4 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well
A)L The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private seater supply -ell'' Method used to determine distance
"This system passes if the well water analysis, performed at a DEP cenified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is Free from pollution Erom that faciliry 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 anached to this form.
3. Other.
This is a split sewage system.
2-5 ' X7 cesspools in series . ron
2-5 ' X7 ' cesspools in series 3 & Rear
3
Page 4 or I
OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 314 Phinneys Lane
Centerville .Mass .
Owoer: Steve
Dise of lospeetion:
D Svstem Failure Criteria applicable to all systems:
You must Indicate "yes" or "no" to each o(thc following for all inspections:
_ �' ackvp of sewage into (aciliry or system component due to overloaded or clogged SAS or cesspool
Discharge or pondtng of eMvent to the surface of the ground or surface waters due to an overloadee or
clogged SAS or cesspool
S'.auc liquid level us tr d�smbuuon box bove outlet inven due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invcn or available volume is less than 'A day now
R quvcd pumping more than 4 times in the last year NOT due to clogged or obstrvcted pipe(s). Number
umes pumped —L.
/may ponion of she SAS, cesspool or privy is below high ground water elevation.
V Arsy ponion of cesspool or privy is within 100 feet of a surface water supply or rributary to a surface
—/water supply
Any ponion of a cesspool or privy is within a Zone I of a public well.
y ponion of a cesspool or privy is within 50 feet of a private water supply well.
Any ponion of a cesspool or privy is less than 100 feet but greater than 50 feet,lrom a private water
supply well Kith no acceptable water quality analysis. (Tbis system passes I(the well water analys15.
perfarmed at a DEP ceriificd 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 cop) of the aoalysis must be attached to this forma
iYcONo) The system fails. I have determined that one or more of the above failure criteria exist as
dcscr bed to ) 10 CMR 15 )0). therefore the system fails. The system owner should contact Inc 90�
Health to determine what will be necessary to correct the (ailtue
E Large Systems:
To or considered a large system the system must serve a facility with a design now of 10,000 gpd to I5,000
gpd.
You must indicate tither 'yes" or "no" to each of the following:
(7hc following criteria apply to large systems in addition to the criteria above)
rs n o
the system is within 400 feet of a surface drinking water supply
e system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nirro cn sensitive area Interim Wellhead Protection Area — IWPA or a ma ce
— Y o g (_ ) Pfl
Zone II of a public water supply well
!i you nave answered "yes" to any question in Section E the system is considered a significant threat, or a.nsweree
CC in Section D above the large system has (ailed. The owner or operator of any large system considered a
s e^.:f czns threat under Section E or failed under Section D shall upgrade the system in accordance with J 10 CMR
`0= The s)siem pwncr should contact the appropriate regional of-ice of the Depanment.
4
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropeM Address:314 Phinneys Lane
Centerville , Mass .
Owner: Steve Heckler
Date of Inspection: 7/26/02
C. Further Evaluation is Required by the Board of Health:
/ d Conditions exist which require funher evaluation by the Board of Health in order to determine if the system
s failing to protect public health, safety or the enyironrnent.
I. S*stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
syssttem is not functioning in a manner wbich will protect public bealtb, safety and the environment:
40 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
' S.N stem 'Ail] 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:
oVA The system has a septic tank and soil absorption system (SAS) and the SAS 'is within 100 feet of a
surface water supple or rributar,, to a surface water supply.
a The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple
.4-0 The system has a Septic tank and SAS and the S 'P AS is within 50 feet of a 'v pn ate water suppl} µell
AP The system has a septic tank and SAS and the SAS is less than 100 feet bu 50 feet or more from a
pn%'ate \Nater supply -ell'' 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 [Tom that facility and
the presence of ammonia nirrogen and nitratc nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are rriggered. A copy of the analysis must be artached to this form.
3. Other.
This is a split sewage system .
2-5 ' X7 ' cesspools in series . ron
2-5 ' X7 ' cesspools in series 3 & #4 Rear
3
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 314 Phinneys Lane
Centerville . Mass ,
Owner.Steve Heckler
Date of inspection: 7 26 02
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
PP mping information was provided by the owner, occupant, or Board of Health
�' Were anv of the system components pumped out in the previous two w ^
/— P P P p o 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 pan of this inspection ?
v 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;.Kluding the SAS, located on site ?
Were th a tic 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
i/ 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/
L Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:314 Phi nneys Lane
Centervi le ,Mass .
Owner: Steve Heckler
Date of Inspection: 7/26 02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual): d
DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: / _
Does residence have a garbage grinder (yes or no):
Is laundry on a separate sewage systerT (yes or no): _D (if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use: (yes or no): AIV
Water meter readings, if available (last 2 years usage (gpd)):2000-12 , 000 gal lops=32 . 88 GPD
Sump pump (yes or no). — —gallons=24 . 66 GPD
Last date of occupancy:
COMMERCLAL/INDUSTRIAL
Type of establishment: .414
Design now(based on 310 CMR 15.203): _� gpd
Basis of design now (seats/persons/sgft,etc
.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no): 104
iron-sanitary waste discharged to the Title 5 system (yes or no):4�jl
Water meter readings, if available:
Last date of occupancy/use: ti'14'
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: None available
Was system pumped as pan of the inspection (yes or no):
If yes, volume pumped: 12Y2 gallons -- How was quantity pumped determined?
Reason for pumping: Heavy scum & solids layers were p ese
TYPE OF SYSTEM
/1ZOSeptic tank, distribution box, soil absorption system
�ESingle cesspool$
_Overflow cesspool,C
/)Privy
,12QShared system (yes or no) (if yes, attach previous inspection records, if any)
.,0Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained ftom system owner)
AOFight tank X Attach a copy of the DEP approval
.(� Other(describe):
Appr ximate aee of all components, date installed (if known) and source of information:
9 -dW /Ar 14.W
Were sewage odors detected when arriving at the site (yes or no):'-�
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION (continued)
Pro pert), Address: 314 Phinneys Lane
en ervi e , ass .
Owner:Steve Heckler
Date of Inspection: 2
Lite PVC'rpipe from #1—#2 Pool .
4 "' Orangeberg pipe through
BUILDING SEWER(locate on site plan) out thr remaining systems .
Depth below grade:
All lines are clear .
Materials of construction: cast iron 40 PVC other(explain):q
Distance from private water supply well or suction line: /V'
Comments (on condition ofjoints, venting, evidence of leakage, etc.)'
Joints appear tight . No evidence of leakage . The systems are
vented through the house vents .
SEPTIC TANK�J` (locate on site plan)
Depth below grade: AO
Material of constructionX( o?concretu.4 metal 4),#fiberglasspolyethylene
/l�other(explain) ,(/t
If tank is metal list age: .U/j Is age confirmed by a Certificate of Compliance (yes or no)oo� (attach a copy of
certificate) —
Dimensions:
Sludge depth:
Distance from top of slud e to bottom of outlet tee or baffle:
Scum thickness: 4,4
Distance from top of scum to top of outlet tee or baffle: i11A
Distance from bottom of scum to bottom of outlet tee or baffle: _AM
How were dimensions determined: 2
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
The septic tank is not present
GREASE TRAD (locate on site plan)
Depth below grade: 4./
Material of construction;�concrete.,O meta 1,4Wfiberglass��olyethylene/W other
(explain): .4
Dimensions: .tf
Scum thickness: A
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.):
Grease trap is not present
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert) Address: 314 Phinneys Lane
Centerville ,Mass .
Owner: Steve Heckler
Date of Inspection: 7/26/02
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: .i'
Material of construction: concrete metal fiberglass.!//_polyethylene,O other(explain):
Dimensions
Capaciry: X 2d gallons
Desien Floe: gallons/day
Alarm present (yes or no):
Alarm level: V/9 Alarm in working order(yes or no):d.
Date of last pumping: NA
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present .
DISTRIBUTION B0Xf (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: d,(�
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box is not present .
PUMP CHAMBEF�(locate on site plan)
Pumps in working order(yes or no): i1%fi
Alarms in working order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump c am er is not present .
8
Paee 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 314 Phinneys Lane
Centervi e , ass .
Owner: Steve Heckler
Date of Inspection: 7/2 6/0 2
SOIL ABSORPTION SYSTEM (SAS): zcate on site plan, excavation not required)
Split system @—cesspools rear ; 2—cesspools front .
If SAS not located explain why:
Located see page 10
Ty p e
leaching pits, number: a
lea g
ching chambers, number:
leachingalleries, number: _
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspools number: A—
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vege(ation,
etc.):
Loamy sand to medium fine sand No signs of hydraulic failure or
are dr . Ve etation is norma umpe
pool . Shou�(cesspool
be pumped annually . Garbage isposa is Ares .
CESSPOOLS: �n be_�umped��,part of spection)(locate on site plan)
Number and configuration: (,� (�J ( J
Depth — top of liquid to inlet inyen-
Depth of solids layer: '
Depth of scum laver ��—
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.):
Same as above
PRIVW'C/ (locate on site plan)
Materials of construction: NA
Dimensions: NA
Depth of solids: NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy is not present .
9
Pagc 10 0( 1 1
OFFICLA.L INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continvcd)
Pfop<rrry naarce,: 314 Phinneys Lane
Centprville S .
Oxocr: Steve Hec c er
Dttt of In,ptctioo: 7 26 02
SKETCH OF SEWACE DISPOSAL SYSTEM
Pro. oc t 1kmh of tht ,cwtjt ditpottl tymm including tict to it Icut two permincnt rcrcrcncc ISJ1Gn� x,
otn<rinvk, loctic ill . 0h .+ithin too (m. LQciic whttc pvblic wit(( )vpply cnicrf the bviloin6.
Sly P�1c�wR�vy S �a�V. c �.V��ftic (lt
\ ` s
L � —
to
Page I I of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:314 Phinneys Lane
Centerville ,Mass .
Owner: Steve Heckler
Date of Inspection: 7/2 6/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_� feet
Please indicate (check) all methods used to determine the high ground water elevation:
§eEcPewMtocWo0aar
ta systemEea
ns on record - If checked, date of design plan reviewed: 16)4
bservation hole within 150 feet of SAS)
lth explain:
Checked with local excavators, installers- (attach documentation)
YES Accessed USGS database-explain: _http : //town barnstable . ma . us .
You must describe how you established the high ground water elevation:
Used ; Gahrety & miller Model . 12/16/94 Ground water levels above sea level .
Used ; USGS ; Observation well data. June 1992 _
Used ; USGS . Technical bulletin 92-000-1 Plate #2 Annual ranges of
groundwater elevations
rou n
Leaching
Pit :eet
Groundwater: Feet Below Bottom of Pit �gh Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the botto
Of the leaching pit and the adjusted groundwater table is / ,�f�
feet.
1
\S
11
�- rnnrn•-n r-►-.-r-irn. mrn mrrnn-in.rnir:•.Tr.+Te.r:+r:nrn r�s- v*.a-�rrs.m. .r+-rr+-�r--r-..-
TOWN OF Barnstable BOARD OF HEALTH r
- T -- SUIISURFACF 9FWA(;E DISPOSAL SYSTFM INNSH TION FORM - PART D .- CERTIFICATION I
-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 314 Phinneys Lane Centerville ,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Steve Heckler
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P .Macomber & Son Inc'.` '
COMPANY ADDRESS Box 66 Centerville , Mass . 02632
5 t r e e t Town or City Stat- n p
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 790 _ 1578
n
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that t)ae inroranation reported is true , accurate , and
omplete as of the time ofeinspection . 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 :
14 S stem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
heRlLh or the environment as defined in 310 CMR 16 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA sectioal of
this form ,
System FAILED$
The inspection which I have conaircted has found that the system fails to
protect the E)ktblic health and the environment in accordance with Title
5 , 110 CMR 15 , 303 , and as specifically noted .on PART G - FAILURE
CRITERIA of this inspection form .
Inspector Signa01
e Date
.-. �.
copy of tfai ert.ification must be provided to the OWNER, the BUYER
arne
Where applicable ) and the 130ARD OF HEAL'1'll.
If the inspection FAILED , the owner or"operator shall upgrade ' the system
within one year or the dote of the inspection , unless allowed or required
otherwise as provided in 310 ChIR 16 . 305 ,
partd . doc