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HomeMy WebLinkAbout0320 SCUDDER AVENUE - Health 320_Scudder Ave. Hyannis A= 288 - 194 i i I r I i 0 TOWN OF BARNSTABLE V LOCATION �'� Scvdd�r G��`-e- SEWAGE# 5/77 VILLAGE ��U�J/14 Sl'�rz" ASSESSO 'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a LEACHING FACILITY: (type) (size) NO.OF BEDROOMS OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 E ?oSt�G 33 PH , 35 DATE 7i29ios _ PROPERTY ADDRESS 320 Scuddea ,4ve •+ / • . liyann.i.6noat Mazz 02647 {itic system at the address above was On the above date, theytie Inspected. i This system consists of the following:. 3/ 1., 2-6X8 cezzpooiz Based on inspection, ) certify the following conditions: 2.! 7h.i,6 .i.6 not a 7.it ie Tive Syztem.- 7h.iz iz a '.6ewage .system 3., Sewage zyztem •.ia .cn paopea woak.iag olden at the paezeht t.imeo SIGNATURE ' 4 Name: Robert A. Pa_ to inl Comypan Jos h P. MB.•e�mhpr R Son Inc . " Address: P. O. Box 66' Ge terville. Mass 02M f'Phone: 5o8 . .� e,434Q Or ana.T75-$412 �r dO%pH P.. MACOMpER & SONt,INC.' Tanks-Ceapoola-t,ea�chfleids •pumpgo &•:Installed Town Sewer•Conneafions P.O. Box 65 Centeiville, MA 0262-0066 775-13p$ .' 77.g-6412 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS !� DEPARTMENT OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM-^NflT.FOR VOLUNTARY SYSTEM FORM MES SUBSURFACE SEWAGE DISPOSAL PART•A CERTIFICATION Property Address: ��n Scu��Pr A_ve u. .11 vprt-- MA 02b47 Owner's Name: Edwin r'arfiPr Owner's Address: "^ Box r A Port -MA 02647 Date of Inspection: lease print) Robert A Name of Inspectors (p� mp•r��Qo 2 & S•on Inc. Company Name' Mailing.Address: a.6,d,:0 2 6 3 2 l • • Telephone Number: 5 0 8=7 7 5 .i333 CERTIFICATION STATEMENT ' at,the information I certify that I have personally inspected the sewage of the ins a ti n. ess and th The insp this ection was performed based on my � below is true,accurate and complete as of the timeP systems.I am and maintenance of-on-site sew training and experience in the proper t to sect on.19:340 o Title-5(310 E14R 154000 age disposal system: a DEP approved system inspector pursuant to , XXXPasses- Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: �t Date: The system inspector shall,submit a copy of this inspection report to the.Appro. . Authority(Board of Health or , y or has:a design flow of 1,0,000 DEP)within 30 days of completing this inspection.If the system,is a.shared system 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 for the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This'reP oft only describes conditions at the time of inspection a nd he future thundey the e conditions same or different „^ time.This inspection does not address how the system will perform conditions of use. —•- -- _.:__�..... �n sn.nnn Page 1 Page 2 of 11 OFFICIAL INSpJKCTIORFORK--NOrT:FOR�VOLUNTA�RY ASSESSNEM SUBSURFACE SEWAGE DISPOSAL SY$TZM INSPECTION FOB. PART'A CERTEFICATION(continued) Property Address• 3 Z 0 S c u clde a A v e Hljt7nn!Ann ig 4. OWMA, Edwin as e,z Dste of.Inspection: 7/2 9/0 5 Inspectiofq St<prnaary: Cb0A Ait',C D or B•/ .UW foompdetW61J of Section.,D A. System Passes:'y E S NO .I have not found any information whic'lr indi$atesIlulf and►of the f8gure criteria described in 310 CMR 15.303.or in 3lO CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 1 Septic uh:f.Pm I A Jn nn, on ' „oa4 4 eol 4 64 e -- G� , .• G4.//C G B. System Conditionally Passes: rz o One or more system components•as described in then"Conditional;Pass"section need to bG t eplaced or repaired,The system,upon completion of the replacement or repair,As approved by the Board of Realt64 will pass. Answer yes,no or not.determined(Y,N,ND)in•the for the following statements.If"not determined"please explah n o Theaeptic tank is.metal.and.aver70 years old*or the septic•tank.(Whether-metal ori0t)131MM orally unsound,exhibits substantial-infiltratip or ex0ration or•tank•feilwe is nut►ine is Systcm will pass utspection•if e existing tank is replaced with'a eomplymg septicu*as rQyed by.the.8oasd 9fHealth. '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 ofd is,available.. ND explain: ' n o Observation of sewage backup or break out or high stiitic water level in the distribution box due to broken or obstructed pipes)or due-to a broken,settled-or unoven distribution box.System will pass inspgcti.en.if(with approval of Board ofH'eslth): broken.pipe(:)arc replaoed. . obstritdij0 is removed' -dfstti iobn box Otveled'or.-1*plaeed ND explain: Art 0 The system required pumping..-more,than 4 times a year due to bt�oken or obstructed pipe(s),The system will pass inspection if(with approval of the Board of Health): �- brokenpipe(s)are replaced obstruction is removed ND.explaim. • c Page 3 of l i � ,ACTION FORM•NOT�'OR�� ORM TS —� Off... JRF'ACE SEW- GE DISROUL SYS . PART-.A . . CER,TWCA11ON`(6otitiat ed) : Property Address:3 2 0 •s c u rLd e a Ave' ftuan — owner:. ' Date of Inspection: C. Furtber Evaluation•is Required by the Board of Health: ; exist wlrichxequire furthor..eyaluatio�ab oar y.the Bd:opHeaith, •ovder to:detffUfte if no Condition s. the syst�tn.• Ts failing to protect public health,.safety or the environment. •. ;.,ith that the 1, S stem will pass unless BoaO•of.Health detdrmin of pitblie health,safety d be ironment: Y system is not fhactionft ib.a•mauhor�which. p Cesspool or privy is.within,SO feet of asvrface water etated wetland or a salt marsh• n o Cesspool or privy is within 50.fee n o t of a bordering v4g ter Supplier;-if any),d$termines:thatthe 2, System will fail unless the Board of iLeaieb{tbPOICba ith,safety and epvlroument: system is functioning Ina,naatlnar.that pro p INI the SAS is within 100 feetof a no The system has a septic tank and soil absorption sY Y surface-water supply or tributary to asurface PP system •a.sepbe tank and SAS and tho:SAS is-witbin a Zone 1 of.a public water�suppYy. na They . • . n o The system has a septic tank and.SAS and the SAS is withins50 feet of a private water,supply well. t and SAS and rho SAS is less than 100 feet but 5r0 feet oF;niore Toni a n clTlie system fias a septic taAk v'� u a private water supply well"-Method used to determine distance' d laboratory,for iform **Thiss stem passes if the well water analysis'performedell at a s free fromepollution from thatlfaeil and Y. bacteria and volatile organic compounds indicates that the m,provided that no-other the presence of ammonia nitroge Honitrate the an ysi nitrogen m st be,eached r.less o••tbis form. failure'criteria are triggered..'A copy 3, Other: Page 4 of 11 OFFICIALINSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 320 Scudder Ave Hyannis Port -MA 02647 Owner: Edwin Carter Date of Inspection: 71 A/Q S D. System Failure Criteria applicable to all systems:. You must.indicate"yes"or"no"to.each of the following:for all inspections: Yes No X Backup of sewage,into facility..or.system component due_to overloaded or.clogged SAS'or cesspool X Discharge:or>ponding of effluent to the surface of the:.ground or surface waters due to.an,overloaded or clogged SAS or cesspool X . Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than.6"below invert or.available volume is less than%.day flow —7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water.supply or tributary to a surface water supply: _ X Any portion:of a cesspool or privy is within a-Zone.1.of a:public well.. X Any portion of a cesspool or privy is within.50 feet of a private water supply well. �. X An portion of a cesspool or privy is less:than 100 feet but eater than 5.0 feet from a iv f o rate water Y P P vY _— P gT P 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 fndicates..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 forlp.4 n o (Yes/No)The system fails.I have determined that one or.more�lpf 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 1.01000 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) . yes no X the.system is within 400 feet of a surface drinking water supply — X the system is within 206 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has failed.The owner'or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 I Page S of 11 OFFICIAL INSPECTION FORM.—NOT F y INSPERCTASSESSMENTS �. SItSURFACE'SEWAGE DISPP S �STE CHECKLIST Address: Hyannis 320 S Portcudder Avg— Property 2 6 4 7 M — , owner: Date of Inspection: Check if the follow have been dyne:You must indicate` g"of"no"-as-to eaeh.of the ollowin Che . Yes No - _ X Pumping information was pro viddd'by the owner,occupant,or Board.of Health _ X Were any of the system components pumped out in the previous two Weeks? X Has the system received normal flows i _ n the previous two week period? _ X , e large volumes:of Water been introduced to the system recently or as part of ths3nspecrion? _ Have g . N/A X Were as built plans of the system'obtained and examined?(If they were not availabletote as N/A) X _ Was the facility or dwelling inspected for signs of sewage backup? �. X _ Was the site inspected for signs of break out? X . _ Were all system components,excluding the SAS-,located on site.?- ened,and the interior of the tank inspected for the condition X . _ Were the septic tank manholes uncovered;op depth of slud a and:depthof scum? depth of liquid, g• of the baffles or tees,material of construction,dimensions, ep• X. _ Was the facility owner(and occupants if diff6rent from owner)provided with inform -- information on ft .roper maintenance of subsurface sewage disposal systems? The size and to cation of the Soil Absorption System(SAS)on the site.has been determ►ft based on: Yes no le lan at the Board of.-14ealth. X Existing information:For exam-. a p _ etermined in the field(if any of the failure criteria related to Part C is-at issue approxiUM'donof distance . X D is unacceptable)[310 CMR 15.302(3.)(b)] , Page 6 of I 1 O1�FI? IA�L jNSpEq:Tj6N:�` } M—laT©T 1�'O�Z V�1Li I' Y ASM$aM ��S SUWU.pFACE•MWAGE�i�;4SA��SiY 1VI;�SPECTION FORM PART:G SYSTEM DMRKAATION PropettyAddress: 320' Scudder* Aye . Hyannis Port MA_ 02647 Owner: Edwin Date of Inspection•_ 7 FLOW CONDITIONS RESIDENTIAL Number of be0roRms(desiig):• , Number ofbedroomg{acWal):_;T_ •, Dl~SIGT1'•flow ba§�:d on'310�1V�t.•1'S:�03'�(for e�ariiplei.I IO'gpd z#'tifbedrooms}f'' • Number of Current residents: ., 1 Does" Idence have a garbage grinder(yes br no): ,n o Is latmdry.on a separate sewage.system(yes or-no):.n oo Elf yes separate b spIption required] Laundry system inspected(yes or no):a o _51 .7 5 0 a.�.�o n z . P t7=l 4/.-7 8 Ses,sonal use:(yes or no): .n o 2003 _ g �/ Water meter r;dings,if available(last 2 years usage(gpd))Z 0 0 4=6 4, 5 0 0 .qa 2 2 o n Si i7 17 6 7 9 Sump pum (yes or no):rz o Last date of occupancy: COMMERUSTRIiL iV/•4 Type of a t: DesT �' on•310 CMR 15.203). apd ft Basis.of S i i'low,(seatsjpersons/sq%otc.): ' Grease tra} $resent(yes or no): Industrial waste holding tank present•(yes or no): Non-sanitary waste discharged to the Title 5 system•(yes or no):•i, Water.meter readings,if available; Lase date of occupancy/use:;-__r___ 1UNERA,L T"QRMATION ' Pumping Reeprds Source of information: es or nd . Was system pumped as part f the inspection(Y )' If yes,volume pumped:j gallons.--How w uantity pumped determined? Reason for.pumping: C TYPE-OF SYi�'EM • _Septic tank,distribution box,soil absorptign system X Single cesspool X .0verAow cesspool _Privy . _Shared system-(yes or no)(if yes,attach previdus inspection records,if airy) _innevative/Alternative.-technology.Attach a Copy of the current operation and maintenance contract(to be obtained from system owner) _Tigbt tank _Attach a.00pyof the.DEP.approval —Other(describe): Approximate age'of ala components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):iJ� page 3 of l l AOy "SMSMENTS • *.MECTION FORl�I-�i SW Sy VOL IN OFPi�I . E S �R DISPOSid►L SUSstw� PART A CRRTIRC ' ritintie cl) A��N(io ' Sc Hr Property Address: 320 Owner:.• e Date of Inspection: uiYed by the Board of Health: C. Further Evaluafion•is Reg , ine ifshe system '�fieaith;in•or�erto;detertYii NO Conditions.exist which.regPue fmther•.e nvir nme y Or the enVirOIIlnetli. B protect public health,,safety t the is failin to pr P ., : es�iti accordance with a3o.C:Ni;t 15:303(1)(h)0a a mattner�whicb:pvul protect public health,safety*'to a.enYironmtof 1, System will Mass unless Board•o#Heal#h determin. system is-not fulardomug� n o Cesspool or privy is•within,50 feet of asurfa"w-ter �s within 50.feet of a bordering vagetated wetland or a salt marsh• n Cesspool or privy , Walter Su lien;if any),datetn►mea-thatthe stem will fall uhe Board of FLCatcb{ � public b lth, m>�tt 2 Sy nless tsafety and eaviron 1n a mariner.that prote . system is functioning _ tem has a septic tahk and soil absotption-system•{SAS):and the SAS is within 100 feet o a n o The sys to a surface water supply. surface•water supply ortrilautary n o The system has-a.SepbtUnk and SAS and the,SAS is=widlin a Zone 1 of.a public water�supply as a septic tank weg- and.�AS`-audthe SA'S is within,50 fad of a privata water.supplY n o The system h 1' and SAS and the SAS is less than 100 feet.but 50 feet ox�rion��!a n o The system has a septic tank v c u p it vate water supply well"'.Method used to determine distance' for coliform erformed at a DEEP certified laboratory., $$This system passes if the well water analysis,p provided that no-other 'le organic compounds indicates that the�vell is to or tessothan 5 ppm>Pro fat facility ap bacteria and volatile g the presence of atlnmonia nitrogen-nod��an y i m gt bo ached tat*form, failure anteria are mggered.'A copy' 3. Other: Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTAR AS ISM SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC PART C SYSTEM'INFORMATION(continued) Property Address: 320 ^��ddPr A Hyannis Port MA 02647 Owner: Edwin f al_ tex .Date of Inspection: BUILDING.SEWER(locate on site plan) Depth below grade. 240 Materials of construction. iron _40 PVC_oth2r0(*xplain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): ao�nt� a/a/2ean ti ht no evidence o Qeaka e. Vented th2ough house vent SEPTIC TANK:no(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass colyethylene other(explain) P attach a co of If_tank is metal list age:— 'Is age confirmed by a Certificate of compliance(yes or no):_( copy certificate) !-` Dimensions: Sludge depth: • Distance from top of sludge to bottom of outlet tee or baffle: 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: Comments(on pumping recommendations,inlet and outlet tee or.baffle condition;structural integrity,liquid-levels' as related to outlet invert,evidence of.leakage,etc.): Se/2•t is tank i s not /2ae,6ent GREASE TRAP:20(locate on site plan) Depth below grade: other Material of construction: concrete metal_fiberglass colyethylene (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee outlet tee or baffle: or baffle: Distance from bottom of scum to bottom of outl Date of last pumping: integrity,liquid levels Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte ty, q as related to outlet invert,evidence of leakage,etc.): G2ea�se t2a/? �� not /LP-13 7 Page s of I I . OFFICIAI.7rKS•FECTI ON FORM NOT FOR VOLUNTARY ASSESSMENTS .4"90 'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C• SYSTEM INFORMATION(continued) P.roperty.Address; 320 Scudder,, Ave Hyann' S .Anrt- MA 02647 Owner..,,,Fi a;pt],Y3 a rf ar Date of Ibspectlon; 7/�?a //n 5 TIGHT or HQLVING TANK;, nO (tank must be pumped at time of inspootion)(locate on site plan) Depth below grade: Material of construetton: concrete metal_fiberglass___polyethylene other(explain)- Dimensions: Capacity:-gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm'ui wo-king•order(yes or no): Dot;of last pumping: Comments(condition of alarm and float-switches,etc.): 7.i,qh;t oa hoid.ina tankA anA n»t �.cnnfn DISTRIBUTION BOX: nO (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): Dis-zt-igu;Lion Ploz L nnf nIzeAvaf r PUMP CHAMBER no (locate on sife.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,ett;.); P umI2 chamgglt 1.6 no.f. -Alz innf Page 9 of 11 OFFICIAL.INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 -(Z-1idde- n17A Hyannis Port MA 02647 Owner: Edwin Carter Date of Inspection: 7 2 9 0 5 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located .3ee /gage �0 Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loam to medium .sand No Z.ic/ns o�e -�a-ihtae oa ponding., So.iiz aae day., Veaetdt ion .ins noama.P_. CESSPOOLS: Y e (cesspool must be pumped as part of inspection)(locate on site.plan) Number and configuration: 2' Depth—top of liquid to inlet invert: Depth of solids layer: 1" Depth of scum layer: 2" Dimensions of cesspool: 618 Materials of construction: C C'n c EC 61 o<--(c Indication of groundwater inflow(yei br no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Loamy to .•med-ium )eine .sand., No z.i nos o a.ieulle., Ve e a ,io t.6 noama • PRIVY: n o (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.): l aivy .ia not R2ezent 9 Page 16 of 11 ' SOT�P'01 'V' ;Tll ARV-ASSES&MENTS Old;•IN$FEO..N' QRM - gE. gVS'I'I<TM jjNWRM''UON(pcntinxedy 3�n c�-n[�Ac�P� property Address: H. annis Port MA 02647 Owner: Edw; „ -rt Pr Date of Insp�. 7/�a. TCH OF S VYAG�•DI CPOSA,LSYSTEM e clu in&des to at Least two perinattetit refarl.��o 1 or a sketch of the sewag dtlsP 1 enters.the building. b dCe! Low all wells within�00 feet.Locate arhere publicw ter supp y F in r - Page 11 of 11 OFFICIAL INSPECTION•FORM NOT FOR VOLUNTARY FOB S �• SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION PART C SYSTEM INFORMATION(continued) Property Address: Hy—'anni� vnrt� 02647 Owner: Edwin Care Date of Iaspectlon: 7/2 91 5 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: -NO Obtained from system design ply on record-If checked,date of design plan reviewed: u e s Observed site(abutting Pr°ppm'/Observation hole within 15U feet of SAS) — "Checked with local-Board of Health-explain: - "•' ` """`� no Checked:with local excavators,installers- n documentation)b tI a•'m a u Meuh®ccessed.USGS database=explain• R �—, You must describe how you established the high ground water elevation: . . a )e Cod Comm.ihioa 7atte Coh !Jatez tou24 find I u�.Qic Gla�ea Sup/�2y ll�sed C Glut? head aotecuo•n anew ma Se t �995 o c commiA ion., e, uaeaGate2 2oe • ping �• • • �( . Beet Groundwater j�,,feet Below Bottom:of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method vl . Therefore,the vertical•scpara ion distance between the bottom 1 of the leaching pit and the adjusted groundwater table is feet. .� • 11 •.MnTM�1i17��mr n� R TOWN p BARN SABLE ElOAIiU-OF HEALTH SUI)SURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - DART D­ CEItTIF1CATION «.afh«r•s's: „s.r'+et's'vnfRnhensirs+�+A�/si�n'1r.""nM*is -TYPE ON PRINT CLEARLY- PROPERTY INSPECTED , STREET ADDRESS 32D. scudder Ave ASSESSORS MAP, BLWK AND PARCEL J------ ' OWNER's NAME E .�.•r PART` D CERTIFICAT30N NAME OF INSPECTOR Ro I iAt j?a.og n i J COMPANY NAME o be h l'•' �lacomIea'' Son Inc Box 66 " Czn�eay.illz l azz' 026�32 ` COMPANY ADDRESS —� Town•or city SkaL� LIP Strout' COMPANY TELEPHONE ( 508. )' T7.5 - 3338 FAX (' 508' )l90 - f 578 5 OM CER'rhFICATION STATEMENT I •certify that. I have persohal'17 .inspected ..the sewage digposa�l .ystem at this address and that t)re information reported .is true,. a.00Ur.ate•, anda omplete as of the time a.-f,•inspection.•. The inspeCtian was performed and any recommendations regarding upgrade, .maintenance ,' and repa•ir .are consistent with my trainii.g and exp.erience in the proper function and maintenance of on site sewage disposal systems ,ifk"• Check one: ' System PASS-b The inspection which -I have conducted has .,nat found any information . which indicates that the system .fails to ' adequately protect .publi-c health or the enviropment as defined in .310 CMR. 15.80. , Any failure criteria oot evaluated are as stated in the FAI�LUR:E CRITERIA section o:f this, form. System FAILED* r ' The inspection which I have con ted • has '•found that •the system fails to protect the public health and the environment ' in acaotd-ance with Title 6 , 310 CMR 15 . 343, and as . specifically noted on PART; FAILURE CRITERIA of this inspection .form. Inspector Signature- Date . .� ne copy of this certi fi.cat•iah must -be provided 'to the .pWNER, the. BUYER where &PP1 i'.owb1*) and th* DQARD OF HEALtil * If the inspection FAILEO., the bwner' .or 9pe'rator Whall upg.rade'•t�he system. within o'ne pear of the dAt•e of the inspection, unless. allowed or required —I-V,__W4a0 na orovided in' 110 CMR '.