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Home My WebLink About0024 MAINSAIL LANE - Health 24-Ma Hyannis 288 065 I q i s No. a 0l)�-S / V Fee �-S THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, M'ASSACHUSETTS 01pplication for W000d *Vote Con!6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( Aband�( �Complete System E5&dividual Components Location Address or Lot No. 2 Y Owner's Name,Address and Tel.No. , I -� l c r! 2 # Q S �i/�H A'.M/�'A. 0 O N r Assessor's Map/Parcel ��I S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Q vv^ f Type of Building: Dwelling No.of Bedrooms 3 Lot Size 7/2 sq.ft. Garbage Grinder Other Type of Building /A Al Gff No.of Persons / Showers Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank A Type of S.A.S. Description of Soil t Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ®e-T • 0 0 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by 0--S, Date // o Application Disapproved for the following reasons Permit No. 2.0 b Date Issued I I 1- -———————————————— No. 0 u(I— S U Fee •� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � - Yes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYfcatfon for Mf6pont bpgtem Cone4ructfon Oermit Application for a Permit to Construct( )Repair( )Upgrade( Abandon(� Complete System .5�ndividual Components Location Address or Lot No. 2 Owner's Name,Address and Tel.No. Assessor's Map/Parcel i /A /I C 0 � 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. r Type of Building: Dwelling No.of Bedrooms 3 Lot Size -7/ 2- sq.ft. Garbage Grinder Other Type of Building 1?f,. Al c i/ No.of Persons Showers( Z.) Cafeteria(. ) Other Fixtures Design Flow gallons per day. Calculated daily,flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /. o o Type of S.A.S. Description of Soil ! t Nature of Repairs or Alterations(Answer when applicable) ' 4Date last inspected: z. I V �l Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. , Signed A A Z" Date Application Approved by 2.f Date—//-/-r A '7' \ Application Disapproved for the following reasons Permit No. :2g i,\l - ,�60 Date Issued /r o L. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance F IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned by `- :w�°� \7�..4L Vc�C` :S ' t��,t 1y1 t o( �� r at- A�,r� C has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. fio N-�dated / 0 Installer Designer The issuance of this pe t hall not be construed as a guarantee that the system will-f nction as de igned. t Date ► b Inspector fir ` rvj II CC11ClFF � CL Ct� ------G --_------.---------- No. '�UJq— S/V Fee 2 J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Zigaal *pgtem Cow5tructfon rlm_ 't Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon System located at 2,1 M� 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 T7 it1 r Date:_,T�/ U Approved by 11- . ► SI Z449 FAILED INSPECTION 77 COMMONWEALTH�OFMASSACHUSETTS —EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS i d - DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED F �.. e SEP 2 12004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_- dy tjAJAWL ,J PARCEL ®( l�ti�n,s .Nth- i»6a� w� Owner's Name: �}�e M aycvr� LQ Owner's Address: Date of Inspection: Name of Inspector:(please print) Nyasa. F'- Company Name:A I Mailing Address: t)K Genk.y✓flle' MA 02 �3Z Telephone Number: ,Safi—347—56c.2 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: Passes Conditionally Passes � Xeeds-Fur�het Evaluation by the L-ocai`approving Authority—' V Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments 7)Ve Ao S,-joe r-<k fa vh ch, re S q c,� �+� G CCU v'd,vl c sV6 �e, ****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 09/06/2004 15:40 15089456006 PAGE 02 COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS M P d DEPARTMENT OF ENVIRONMENTAL PROTECTION aK TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Zy 0r41AIS'L Ind 4114Y14"t , 8 A ouo! Owner's Name: �� h4veano Owner's Address: Date of Inspection: -) —p Name of inspector:(please print /tteNAtt Ama f Company Name: S,# kcwtz Mailing Address: t ntnwrr,it or, C.eAkeut lie 1 J•I A Telephone Number: Soft — 3i;7—.S664 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 1.5.340 of Title 5(310 CMR 15.000). The system: _ Passes Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: /► ,�� Date: • /'L— 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. r Notes and Comments �,y e p/1 /tit' /"�yt�t,✓ v,c 6P C fLM it eh t/ S1 ' wov!J Sue of F,te- tylw� passes. Tie y_ 6nor w4 c nee GCr�s;bk re oh a s�ertk s.{sk !� A60% 4 (e%#00. ****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 ] 09/06/2004 15:40 15089456006 PAGE 12 Page 11 of 11. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: Zu KAAAA l %—A ouv� Owner: —roe- Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water�D k feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design.plans on record-If checked,date of design plan reviewed: 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) Fee+id oric%r►A%1 Accessed USGS database-explain: You must describe how you established the high groundwater elevation: V-e,j ,p.� u s iW fo5ykphtt_ eI&P . 04% &AN M Co^a raur \Inc.A So!$561 Z O'+ �4cs orn�� a�i+QV" 24c�lo.�iw. . Title:5 Inspection Form.6/1.5/2000 11 09/06/2004 15:40 15089456006 PAGE 11 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2M AAJNS��—� w1 I OtiO J Owner: .fie AArI64 Date of Inspection: kJ I y 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, Propert ofi Joe Marcone 24 Mains'( Lane Hyannis, MA 02601 6' diameter cesspool House 4 � � 1• r� �� Beck g House 12.17 10.00 Lv `p 1000 gallon septic tank Title 5 Inspection Form 6/15/2000 10 09/06/2004 15:40 15089456006 PAGE 10 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Zy M A INS L LJJ a aZ4o+ Owner: Date oflnspection: -1?-0 SOIL ABSORPTION SYSTEM(SAS):r(locate on site plan,excavation not required) If SAS not located explain why: Type _ leaching pits,number:_ _ leaching chambers,number: iteach.ing galleries,number: . V.leaching trenches,number,length: VAAkrM„t 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.)° CESSPOOLS:Z(Ilsspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 4" t.3�O.e 'Cwwt etel b l0dL Depth-top of liquid to inlet invert: + Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: CJM r-re JG b Is 4 Indication of groundwater inflow(yes or no):_0 Comments(note condition of soil,signs of hydrauliq failure,level of ponding,condition of vegetation, etc.): PRI'VY: (locate on site plan) Jf �� Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Tide 5 Inspection Form 6/1.5/2000 9 09/06/2004 15:40 15089456006 PAGE 09 Page 8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:--2x MAlss L l 164 4r lipt oZ 601 Owner: -YoiL ,1<'k x`uji.& Date of Inspection: R 1�210"l TIGHT or HOLDING TANK:_(tank must be pumped at time of i.nspecti.on)(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:zof present must be opened)(locate on site plan.) Depth of liquid level above outlet invert: u.i ue k e m%t ,tJ 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.): 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.): ----� 90eiet,, k 4soo4 b k- C4.3 t wcAk era/1 w ks VW%(-Je A-o gcceW„ ��►- Kok. (Ax Inane owNLV OAO)c-41�-46 10-e 'D-Gcvr was \XA)6t� t>%' C&N', u n JC.r "A ZS Lo(\erek Wt..1ICwCA 4fad'\d"'� %3 e His foe tH , 6;1%o qw\ ta%4 -f� wa.AkUw.•-\' des��H e+J too bo `��c7�-•n.. �j�� Z T^d'")%00- 1-u P- s o X v:i&S U50'04m Akk 1;\.,i J \e ok15 wwe- c,A*coh k v Title 5 Inspection Form 6/15/2000 8 09/06/2004 15:40 15089456006 PAGE 08 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2H AALNW1 LA >lanei�►hl'� Owner: L40L, S�lG,Y4�.e Date of Inspection: ��. BUIILDING SEWER(locate on site plan) Depth below grade: 2 " Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: /1//T— Comments(on condition of joints,venting,evidence of leakage,etc.): _40 sheYlr nF ILG�et� SEPTIC TANK:Azoocate on site plan) Depth below grade:AS Material of construction::Z'oncrete_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: to S� �� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 6 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 baffler,�4- How were dimensions determined: fRoG , !NeI'e~ S f-'elL $::kS h J,jM Comments(on pumping recommendations,inlet and outlet tee or baffle c dition,structural integrity,liquid levels as related to outlet invert evidence of leakage,etc,): h. eAAPemeeD l3 be: M 40aJ eo/Idi�rdri � krr&f AA J wu✓k"' r< I j I r GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Di stance 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.): Title 5 Inspection Form 6/15/2000 7 09/06/2004 15:40 15089456006 PAGE 07 Page 6 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 MA;mS L Ll� IT s�� olio I Owner: "9 L I.4atr c Date of Inspection: >�• ��-oy FLOW CONDITIONS RESIDENTIAL 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): Number of current residents: \ Does residence have a garbage grinder(yes or no):N'o Is laundry on a separate sewage system(yes or no):Wj [if yes separate inspection required] Laundry system inspected(yes or no): S Seasonal use:(yes or no): A 0 �G t�9 ll Water meter readings,if available(last 2 years usage(gpd)): 2 DOZ 6;•7 Qp } 3 9 P J Sump pump(yes or no):A O 1 JJf Last date of occupancy: Wr rtA) COMMERCIAL/INDUSTRIAL Type of establishment:Design flow(based on 31.0 CMR 15.203): gpd / Basis of designflow seats/ ersons/s ft etc. : ( P q ) 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 iii Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--.How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Singlecesspool -•^ -6r \&,rudet1 _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 D.EP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Title 5 Inspection Form 6/15/2000 6 09/06/2004 15:40 15089456006 PAGE 06 Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2A MAINS'Ltrig 1L� Q%4 O\ Owner:` Yt.dHp Date of Inspection: \*2 0y Check if the following have been done.You must indicate"yes"or"no"as to each of the following; Ye ' 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? J *as the system received normal flows in the previous two week period? V/ Have large volumes of water been introduced to the system recently or as part of this inspection? MIA Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back tip? y — Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _f _ 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 Cis at issue approximation of distance is unacceptable)[3.10 C.MR 1.5.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 09/06/2004 15:40 15089456006 PAGE 05 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7t4 AA IKS,L Ld 1�a,�11Jt5 � !�� ot6ot Owner: 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 fQ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool N_p_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ 11)0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 1;0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow NO Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped % . _ co:0 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. N� 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. 11 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 31.0 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 1" +r 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) 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 MR, 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 inspection Form 6/15/2000 4 I 09/06/2004 15:40 15089456006 PAGE 04 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 /741JU.s1„ 113hNArIS nA o260t Owner:--Me— ryw � Date of Inspection: 6�•Z.-10 C. ]Further Evaluation is Required by the Board of Health: V' 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 31.0 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: Title 5 Inspection Form 6/15/2000 3 f 09/06/2004 15:40 15089456006 PAGE 03 Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1_4 t4 �1VS�L I� . i A { Owner: T �V Date of Inspection: 06- t Z n L- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: Y I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments--e� I A ! ' e. —5!y r- syskw�. aQpw(s '�o b#- j&%)fO, 114 TSSoE S a s to CA%..1& .uob1rs4 Le se j?eol B. 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 rep]acement 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: Title 5 Inspection Form 6/15/2000 2