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HomeMy WebLinkAbout0208 LEWIS POND ROAD - Health i=-- f3o'208 Lewis Pond-R.oad A'Cotuit A = 020 132 it I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Lei 208 Lewis Pond rd Property Address Nick Walters Owner — — ---------------- ------------- -- Owner's Name/ cr) information is b required for every Cotuit Ma 02635 _— 9/12/16 page. City/Town State Zip Code Date of Inspection N y . Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information �S' filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain ran Company Name 8 Johns path Company Address S Yarmouth Ma _ 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ 9/19/16 I spector'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. ****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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 ofQ17 Commonwealth of Massachusetts - Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r-- 208 Lewis Pond rd r' Property Address Nick Walters Ovvner Owner's Name information is re quired uired for eve COtult Ma 02635 9/12/16 r, page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: Z 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: System has a 1000 GI septic tank as well as a 1000 GI leach pit. Pit is functioning�roperly with no water or higher visible staining. 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 replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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).- El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts _ W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Pond_sue 208 Lewis Pd rd-- -- Property Address Nick Walters Owner Owner's Name infdrmatifo isr every req uired for Cotuit Ma 02635' 9/12/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: - Yes No ❑ ® Backup 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 clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters _ Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 — --- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. ❑ ® 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. ❑ M 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. 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 El❑ 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 - - -- ------_.. .-------------- - ---- Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes 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? ❑ ❑ 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 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? ® ❑ 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: ® ❑ 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 approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address — --- --- - — --------------•----- Nick Walters Owner Owner's Name — - — - - - information is required Ma 02635 9/12/16 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information Description: System has a 1000 GI septic tank as well as a 1000 GI leach pit. Pit is functioning properly with no water or higher visible staining. Number of current residents: 2 -------- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available last 2 ears usage d 183 Gpd 9 ( Y g (9p ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: -- . Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq..ft., etc.): --- --- ----- ----- -- Grease trap present? ❑ Yes ❑ No , Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - ----- ----- ---- --- --- 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s tl 208'Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system T ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins^3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters _ Owner Owner's Name information is Cotuit Ma 02635 9/12/16 required for every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 Plus years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): _ Depth below grade: 1feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): — -- - Distance from private,water supply well or suction line: feet, Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain). . 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: - ----- --------- --- Sludge depth: -- ----- t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form — _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet 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: Date 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 _ 9/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date ----- ------- --------- -- Comments (condition of alarm and float switches, etc.): t *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 1 ille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^� 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is regGired for every Cotuit Ma 02635 9/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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 ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments a 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is Cotuit Ma 02635 9/12/16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑. 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.): Pit is dry Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts :. Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e� 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out 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.): 151ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is Cotuit Ma 02635 _ 9/12/16 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Lewis Pond rd Property Address Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 9/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water r ❑ Check cellar Shallow wells 10+ ft Estimated depth to high ground water: feet Please indicate all methods used to determine the hig h ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan of nei hchbborin property p operty shows NGE at 10+ ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ll s � � MOM vow 'OSAL S '`STEIYI iisposal sys �m ix�cluh �s tot bast `braexaanet rs +�arceatn ks yet: Locatewer �puhcwtru P ent�xsi the blda a oo •� � ��. 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A'� "�ial r 3 � �a n,rnAu "Into �'� t`5 a U4 ;'., "9, , y. .�,� S, x WEI _'.+ '3'g' n 3Pr✓ z ar:. iP �, st pr:,.{ r 3.".:, { r ,� pa :�pP u. *,s'4'z :...„,,� `. �. ,.� �f� �.� ' ' 1 "�»' � � - _ � to ,i, i —Roll Sri i �, r fib.; 4 � p a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 208 Lewis Pond rd Property Address —----- Nick Walters Owner Owner's Name information is required for every Cotuit Ma 02635 _ 9/12/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owners Name information is Cotuit MA 02635 02/02/13 . required for every page. City/Town State Zip Code. Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, D use only the tab 1. Inspecthr. key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections m Company Name PO Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i CZ 02/02/13 Inspe ors 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. ****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. t5ins-11/10 Tae 5 offcm1 Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02/13 page. Citylrown State Zip Code Date of trspeotion B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: 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 replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or not determined'(Y,N, ND)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 exfatration 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. ❑ Y ❑ N ❑ ND(E)iplain below): t5ins•11/10 Title 5Official Inspedion Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts inw Title 5 Official Inspection Fortin ol Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635. 02/02/13 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑,N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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 310 CHAR 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 Thins•1 it10 Title 5 O firiai Inspection Form:Subsurface Sewage Disposal System•Page 3 of f 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02/13 page_ City/Town state Zip Code Date of Inspection B. Certification (cunt.) 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 welt'". Method used to determine distance: This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup 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 clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow t5ins•11/10 Title official tnspectim Form:Subsurface Sewage Disposal System•Page 4 of 17 1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not fo'r Voluntary Assessments r( 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is ery Cotuit MA 02635 02/02/13 required for ev ' page. Cityfrown State Zip Code Date of Inspection B. Certification (cone) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any 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 fecal coliform bacteria indicates absent'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 and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria emst 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. For large systems,you must indicate either"yes"or ano"to each of the following,in addition to the questions in Section D. 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 faded.The owner or operator of any large system considered a significant threat under Section E or faded 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 Departfnent. t5ins•11/10 Tie 5Of vial Inspedion Form:Subsurrace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments �t 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Flame information is required for every Cotuit MA 02635 02/02/13 page. Cityfrown State Zip Code Date of inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes 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? ® ❑ 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 part of this inspection? . ® El available 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,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: ® ❑ 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 approximation of distance is unacceptable)P10 CMR 15.302(5)J D. System Information Residential Flow Conditions: 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): 330 t5ins•11/10 Title 5Offcial Inspection Fort:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.. •'°` 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02/13 page. City/Town State Zip Code Date of inspection D. System Information Description: Number of current residents: . Does residence have a garbage grinder? , ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No ` Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: ' Sump pump? r ❑ Yes ®. No 10/12 Last date of occupancy: Date Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 1.5203)` canons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tide 5 system? ❑ Yes ❑ No Water meter readings-,if available: t5ins•11/10, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is cotuit MA 02635 02/0M3 required for every City/Town State Zip Code Date of Inspection Pection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information ' Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Micial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed(if known)and source of information: 30 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.1 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: 0.8 feet Material of construction: ®concrete. ❑metal ❑fiberglass ❑polyethylene- ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 gal Sludge depth: 3" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02/13 page, Citylrown State. Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured 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 tank was sound and tight with tees in place and liquid at outlet invert . Grease Trap(locate on site plan): Depth below grade: few Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene El 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: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface'Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every CotLi t MA 02635 02/02/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02113 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet evert 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.): . There was no box present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required):, If SAS not located,explain why: t5ins•11/10 TMe 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 208 Lewis Pond Road " Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is COW MA 02635 02/02/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® teaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has a 6'A'precast pit surrounded by a foot of stone.There was no sign of ponding or failure. Cesspools(cesspool must be pumped as part of inspection)(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 ❑ Yes ❑ No t5ins•11/10 Trite 5Official Inspection Form:Subsurrace Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposals System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•11/10 Title 5 Qfrsial Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is Cotuit MA 02635 02/02/13 required for every i page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view 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 budding.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 26 rear 9 47 24 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is required for every Cotuit MA 02635 02/02/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 20.0 Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ 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) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: IUSGS maps show an elevation of over20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form K Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Lewis Pond Road Property Address Tracie Grover and Pat Avalone Owner Owner's Name information is Cotuit MA 02635 02/02/13 required for every e. City/Town State Zip Code Date of Inspection page. E. Report Completeness Checklist ® Inspection Summary:A,B,C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ' t5ins•11/10 Tie 5 0fficiat bspection Form:Subsurface Sewage DPI System-,Page 17 of 17 •4` Y4 ` ~. 4 Date 9-/3—// N To Whom It May Concern: I, 01ZA IJ voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health (Agent or Health Inspector)to inspect my dwelling unit located at aDB ` eu��5 �orl� /�� � in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on f f{ 1` ! ! !d A I hereby authorize and name ate of inspection) to be my tenant representative for the (Occupant representative) purpose of this inspection. is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified F above, and must be renewed for any future inspection(s.) Occu ts,Signab4 _ \ Date Occupants Representative Signature \ Date Q:\Rental Ordinance\inspection permission 2.doc s_ t TOWN OF BARNSTABLE BOARD OF HEALTH G� 11 ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date ( — — l Time: In Out Owner Tenant C' _ - Address 7 b � Address a o O.o J- Complighce Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilitiesv�ti w. RD cast; i- 3. Bathroom Facilities 4. Water Supply . 5. Hot Water Facilities ,. 6. Heating Facilities ` 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use _ 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 3 CA). � 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms �� Number of Vehicles Allowed max) Number of Persons Allowed (max)_ 4 �77En�z" Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here � TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date 10 Time: In Out 6 C Owner Tenant C Address Po I Address 0 `� Complia ce Remarks or Regulation# YesX NO Recommendations 2. Kitchen Facilities Approved.. . -^- --" 3. Bathroom Facilities 4. Water Supply 1f"'� 5. Hot Water Facilities 6. Heating Facilities ` 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities- 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing �/ 18. Driveway Width ���� a 13 IL r. 70 19. Number of Tenants Observed T,v_ PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition 2 Number of Bedrooms 3 Number of Vehicles Allowed (max) J Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here APR 1 2005 f a•, TOWN OF BAR.NSTABLE HEALTH DEPT. DATE 3i23io5 PROPERTY ADDRESS 2os Lewis /Pond. Road aw Cotait Nazz 02635 On the above date, tfi"eptic system at the address above was Inspected. ;,AP _� -�-- This system consists of the following: 1., 1-1000 gai eoa zept.ic tank. E'r�Ctt. 2., 1-1000 ga 2$on .2each.ing pit.- Based on inspection, ) certify the following conditions: 3., 7h.i,3 .is a t.iiee Zive zept.ic zystem (78 C-ode). 4., The zept.ic zyztem -zz zn paopez woak.ing oadea atA- E time.. Leaching pit ways day at time o� .in pect.io SIGNATURE Name: Robert A— Paoilni Company: Joseph P. Macomber A Son Inc . Address: P. O. Box 66' - Centetvilie, Mass 0202 Phone: 508-775.3338 or 508-73 j0SEPH P. MACOMBER &' SONS,INC, • s • Tanks-Cea:pools-lepchfield . •Pump40 &.10611ed •• . •Town Sewer.•Conne�iona .0, Box 65 . Centerville, MA.026z`0066 p •77Si8W . 7-754412-- COMMONWEALTH OF MASSACHUSEWS EXECUTE•OMO OF ENVIRG9•NMtNTAL AFFAIRS 1?EPARTMEN7OFI+.NVIROXONTAL PROTICTION ,a s w r ° 111 LE S OFFICIAL INSPF;CTION FORM--.NQ:T,'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTF4M FORM PART•A CERTIFICAT-ION. Property Address: 08 Lea'.i,S I ids Ro ad' o u.i.t fla. Owfier's NameQu-inn No o 2 e. Ownef s Address: z a M e Date of Inspection: 3/Z 3/0 5 Nanle of Inspector: (please print) /3,a 4,zt Pg.o.0 ai . . Company Name: 1: P.,Nacom&e,4- & .SO 140. Mailing-Address: • �n Qay.t e, .a.ab.•02¢32 •. . Telephone Number; 5 0.8—7 7 CERTIFICATI.ON STATEMENT I certify that I have personally inspected the sewago disposal.systgtA at this address aad that'the.infformation reported below is true,,accurate and complete as of the time of the inspecdon.The inspoction wat performed based on my training and experience in-the proper f etion and m6tenance Qf on.$ite sewage disposal systems,I am it DEP approved system inspector pursuant tb:S ction•1S:340.of•'lbitle 5(31e CMR45:E100). The system: XX" Passes Conditionally Passes Needs urther Evaluation,by the Local Approving Authority all Inspectorlt Sign9farm. Date:' The system inspector shall submit a copy,of this inspection•rieporito the-Approving Authority(Boftd of Health or DEP)within 30 day,s of compleft this inspectiop.If#bye systepi is si. cad sy n or has a design flow of 10,000 gpd or grramr,.the inspector and the system'owner.shall'submit t�a 00ort to the appmprIate Yeglonal•offiee of the DEP.The original should be sent wft Systam mmm auud WOns Sant to dt boyar,if uppiica6le,and the appmving authority; Notes and Comments . ,i•. , ' ****Tbb'report only describes conditions at the time of inspaetlftand under the conditions of use at•that tube.This Inspection does not address how the system will perform in the tlttum under the same or,different conditions of use. Page 2 bf 11 OFFICIAL INSPE,CTION;F++ORM-NO.T F'GR"VOLUNTAR-Y ASSESSN 1'�I'li'S SUBS.URFACE SEWAGE IIISPOSAL SYSTEM.INSIESEC�`ION•FOB PARTA CERTMCATION(continued) Property Address:208 Lew•iz Pond Road o u.it Na Owner: Quinn No one, Ditto of.Inspection: C �/ BVA�YS:..00mpiete�all of Section.D Inspecttoin•Sr�mmary:� Chec�C ;A;#i-, ��;D or A. System Passes: NO l have not found any information which indibates-thitt any of the fallure ctiteria described in 310-CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: septic .s B. System Conditionally Passes: NO. One or more system components•a�described in the`'Conditional;Pass".7section•.need to be replaced.or repaired.The system,upon completion of•the replacement or repair,as approved by the Board of Idealtli,will pass. r— Answer yes,no or not.determined(Y,N,ND)in-the for the following statements.If"not determined"please explain. NO • The septip tank is-metal;and ovcr ZO years old*or the septic-tank(whether-metal.ornot)is-structumlly ine i#:S stem will ass inspection-ifthe unsound,exhibits substantial.infiltration or exAltration.or t. -failure � n �' p existing tank is replaced with'a complying septic'tank es;.ppr�yed by the-.*B d pf-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: NO. 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 brokep;se*d.or uneven distribution box:System will pass inspgction.if(witli approval of Board of Health)' broken.pipe(s)are replaced. . obsWetoa is removed' distfibiitibiibox islovel�d' -replaced ND explain: ,� M NO 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 pipes)are replaced obstruction is removed ND explain: i _-_. , ._._ _.__.._- a �- _. ._- • __�._-___.._ Psge 3 of I I O iCI ,L MFECTION FORMw N©T OR iV'fJLUNTA►TtV ASSESSMENTS' SUS6'URF CE IISROSWL SYSTIM�nvs�CTIQN, . PART A.. . CjZRT-MCAT 0N'(4oiitnxred) : , Property Address: 208 Lewis Pond- /load o uZ (�a owner:. (luinn Done Date of inspection: C. Further.Evaluation-is Required by the Board of Health: NO Conditions.exist whichreypire further•.evaluatfon•by.tha,Btd:of�Heaith;in order,to;detertriine ifthesystem is failing to protect public•health,.safety or the environment. ( )( ) 1. System will Mass unless Board•ofHealth determ4nes+in a�Cordance with 810 CNift)15:3031 .b that the 'system is-not fun+ctionibg if.a mattner�vhich=wlll•protect public health,safety.atrll•the;-W Me Cesspool or privy is.within,50 feet of assurfacewater of•aborderin etated wetland or a salt marsh• e s ool privy is within 50 feet g v4 8 __•_ C or vY s P P 2. System will fail unless the Board-of Health{and Public Water Supplier,-if any),determines that the system is functioning in a mariner.that proteets thr public health,safety and environment: NO The system has a septic tank and soil absorption•system•(SA•S):and the SAS is within 100 fe.etof a surface.water supply ontributary to a surface water supply. . NO The system-has a:4epfc tank and SAS and the.SAS isiwjtltin a Zone 1 of a••public water.-supply. They P NO system-has a septic-tank anOAS:andtho US is Withinf50 fees of a private water.supply well: \• — N0 The system-has aseptic tank and SAS and the SAS is less than 100 feet.but 50 feet orxdore fronl a private water supply well".Method used to determine distance V ZSIIAL **This system passes if the well water analysis,performed at a DEP certified laboratory,for coil€orm bacteria and volatile organic cm ipounds indicates that the Wallis.free from•pollutiou from that facility and the.presence of ammonia nitrogen an 8eli 4 d nitrate nitro is equal to or.less than 5 ppm,.provided that no-other e . failure'crfteria are triggered.'A copy of the analysis must boattached to•tl#is form. • B 3, Other: Page 4 of l l OFN'ICi-AL•I)`iSPEC"&IQN'FORM+NOT R;�Q UNTARX ASSES MENT3 ICI L RFA E SEWAGE DISPOSAL' SYSTEIVI.1WSI'ECTI.0N•FO14 M PARTA CEIL'TIFI�'FI�N, (pontimed) Property Address: 208 Lewis P and Road o u.i. Owner: Qttznn 'Moose_ Date of Inspection: D. System Failure Criteria applicable to all systems:. You must.indicate"•yes"•or"no"tp each otthe:fpnQwitig�for 1bmoections. Yes No ••• � - - X Backup of sevi►Age:into�fat iity:or syst$ni eQinponent•duetooverloaded:ot clogged•SAS or.cesspool X' Discharge:or-ponding of.ofiluent to the.sdrfacG Ofthci round or•.surface:waters due to Anaverl4aded or clogged SAS er cesspool ' X Static liquid level in the distribution box above•outlet invert due,to an over-lbaded or clogged SAS or cesspool `�,�� X Uquid depth in-oesspool is less than.6"below invert or,availablevolume is lest than I day flow —_ —7 Required pumping more•than•4 times in the last year NgT due to vlogged or obstructed pip*).Number of times pumped water elevation. X Any portion ofthe SAS;cesspool-or privy is below High ground —' —7 AAy.portion of.cesspool or privy is within 100 feet of a surface water supply or tributary to a surface -r- water•supply. X Any portion.ofa•cesspool•or•privy+is'within•a7one:l.bfapublic.well.. —k Any portion of a cesspool-or privy is within.50 feet of a private water supply well- -7 Any portion o€•a,eesspool•or privy is less than i00 faet but•greater..thgn 50 feet from a•private•water supply well with no acceptable water quality."Ysis..['I'his•s�'stem passes if the wenwaterpounds sis, performed at a DEP certified laboratory,for conform bacteria and volatile orga nic.comoun from ollutioal're� �-f elft and:thg presence'of adtmonia indicates the well is free fr p nitrogen-and provided that no other failure criteria nitrogen-and nitrate nitrogen is equal to or less than•5•ppm, -are-triggered.A copy of the analysis•niust be attnehed.to this fob.] NO •(Yes/No)•The system &.•I•have dotbrmined that one or.•.more of the:above,failure criteria exist as \ systeg=fails.The-system ownenshould contact the Board of described in 310 CMR 15:303,therefore the Health-to determine what will be-necessary to correct the failure. E. Larp Systemsa d to 15jQ00 To be considered a large system•4he:system must.serve.adaeilltywith adesign flow of 10�000 gp , gpd. You must indicate either"yes"or"no"to each of tho following: (The following criteria apply to large systems" addition to•the criteria•above)• yes no , 1 _ X the-system is within•400 feet of a surface'drinking water su PP Y _ X the system is within 200 feet of a tributary.to a surface drinkin8 water supply X the:system is located to a nitrogen sensitive arks fnterim wellhead protection Area IWPA)or a mgpped Zone ll of a public water supply well If you have•answered"yes"to any question in Section E the system is co�Asida a a significant thre n de answered "yes"in Section D above the large system has failed.The ownevor operator . anylargem in accordance �with 310 CMR significant throat•under Section E or.failed under Section I)-shill upgcad y al office.of the Department. 15,304.The system owner should contact the appropriate region • 4 A Page 5 of.I ECTION FORM N OT Fok VOLUNTARY ASSESSMENTS OFFICIAL INSP gtBSURFACE'SEWAGE DISPOSAU� STEM IN�EC'FION'FORM FAR CHECKLIST Property Address: 208 Lewi4 Pond Road Owner: 0u-i2n ooae � Date of Inspection: 5 ` Check if the followinghgve been done.You ust indicate` s"'or"no"-as-to each.of the following: Yes No X pumping information was provided-by the 4.wner,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 in the previous two week period? _ _ _ X Have large volumes-of water been introduced to the system recently or as part of the inspection? X Were as built plans of the system'obtained and examined?(If they were not hvailabletote is N/A) --r: - X Was the facility or•dwelling inspected for signs of sewage back up? X_ _ Was the site inspected for signs of break out? X. _ Were all system components,*,�uditlgthe SAS;located on site.? and the inteior of the inspected for the X _ Were the septic tank manholes uncovered,:open d of liquids depth of slu ge and depth of scum?pion of the baffles or tees,material of construction,dimensions, p rovided with information on the proper X _ Was facility'owner(and occupants if Siffbreflt from awnei)p \ maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System @AS).onthe stte.Uas been detern ted based on: Yes . no le lan at the Board oMealth. X Existing information:For examp. a p X _ the failure criteria related to Part C is.at issue approxini�tion•of distance . Determined in the.fie�d(if any of is unacceptable)[310 CMR 15.302(3)(b)] I o Page 6 of 11 U1F'FIIALSPTCT IaUi!1:: } -1�!10T 'Olt Vf3I:,iYN'I':Pl`RY ASfiE �N>�1�1' S SYWM SUWM- ACF,-S A � OLFOiF ? PART•.0 SYSTEM•WOIt1yiATIOAI PropettyAddress: 208 Cewiz l oncl Road o —ai a Owner: Quinn. 002e Date of inspection: 3/2 3/ 5 FLOW CONDITIONS RESIDENTIAL 3 Number of bedrooms Number of bedrooms•(actual): G X�.10=3 3 0- %D MIGN••flowbased oa•3'10 CMA 15.203':(for eltai4lei-110 gpd z lt•ofbedrooriis): Number of current residents: .. 2 Does-residence have a garbage gnndg.(yes br 49019i o Is laundry on a separate sewASe.system(yes or.no):.no [if yes aepgrpte ireOon required] Laundry system.inspected(yes or no): , .' 2003-10, 000 ga2.2ons G%1�-27,, 39 Sessonaluse;(yesorno�te� Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 4=15. 0 0 0 qa 2 o n G%[�=41. 0 9 Sump pump(Yes or no): n o Last date of occupancy: z e a z o n a r COMMERCI I ,, USTMAL . Type of estar N flow. n•310 CMR 15.203):. gvd• $asis.of dk0ow(seats/,persoin /sq%t tc.):, Grease trapiresent(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 oecupancy/use:, OTHER•(desgri - . CANERA,L INFQA,tTION q Pumping Records Source of information: NA 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 • X Septic tank,distribution box,soil absorption.system • . _Single cesspool _.Overflow cesspool _Privy Shared system-(Yes or no)(if yes,attach previous inspection records,if airy) Innovative/Alterttative 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): App25roximate age of ale components,date,installed(if known)and source of information: = yeaas Were sewage odors detected when arriving at the site(yes or no):n o Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOL .S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A PART C SYSTEM INFORMATION(continued) Property Address:208 Lewis Pond 12oad Co.tu.it Ala Owner: Quinn ooze Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of jofnts,venting,evidence of leakage,etc.): SE _PTIC TANK. Ye-locate on site plan) \� Depth below grade: 8 n Material of construction: X concrete—metal,_fiberglos Dolyethylene other(explain) If tank is-metal list age:_ Is age conrmeii by a Certificate of Compliance(yes:or no):_(attach a copy of certificate) Dimensions: 8' 6"L X 4 ' 10"V X 5' 8" fl Sludge depth: tzace. Distance from top of sludge to bottom of outlet tee or baffle: t z a c e Scum thickness: t d a c e Distance from top of scum to top of outlet tee or.baffle:t a a c e Distance from bottom of scum to bottom of outlet t;e or baffle:=a c e How were dimensions determined; m e a u 2 e Comments(on pumping recommendations,inlet and outlet tee or baffle conditio structural rote as related to outlet invert,evidence of leakage,etc.): n' !fin',liquid levels %an blimp zz/L.4 LC nlInnO,��nn t .Inlet & OILtPet tees ate in /1QaCe sound. GREASE TRAP:/ O (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass'__polyethylene_other (expo). 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.): 472eaze t2a/2 i.6 nol nno.Son� Title S Tno++crtinn Fnrm A/1 7 age 8 of I I OPTICIAL l S-FECTION FORM NOT FOR V NTAR-Y ISSESS FOIMEM TS yo,,OE SE'S�VAGE DISPOSALQN ARSYSTEM SYSTEM INFOI MATION(continued) Property Address: Zo8 u e 2. Road Owner:.Quinn 'Noolt Date of lt. spectlon, 3/23/05 TIGHT or HOLDING TANK:NO (tank must be pumped at time of inspection)(locate on site plan) Depth Wow grade: g __._polyethylene y ( P ) Material of construction: concrete. metal fiberglass of eth lene other ex lain Dimensions: gallons Capacity: g 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 flaat-switches,etc.)'. 71ght o2 hoi d.in . tanks aai DISTRIBUTION BOX: ND (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distributioij to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Diz.t2.igut.ion Sox .is not PUMP CHAMBER:NO (locate on sife.plon) �\ Pumps in working order(yes or.no): Alarms in working order(yes or no): Comments(note condition of pump chamber,egndition of pumps and appurtenances,etas.): lum chain&e 8 r Page 9 of 11 OFFICIAL INSPECTION FORM--NOT•FOR VOLUNTARY ASS.ES5MENTS SUBSURFACE-SEWAGE.D1SP•OSAL,S- ST,UM INSPECTION-FORM i PART—C SYSTEM INFORMATION(-continued)- Property Address: 208 Lew.iz Pond ad o u.� Owner. Quinn voolLe Date of Inspection: 3/2 3/0 5 SOIL ABSORPTION SYSTEM(SAS): `(locate on site plan,excavation�rot'regtiired) If SAS not located explain Why,. Located .see page Type X leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions:. overflow cesspool,number: _innovadvb/alternative system Type/name of techgology: Comments(note condition of soil,signs o€hydraulic failure,level ofponding,damp soil,condition of vegetation, l it was hydaau..2.ie ai�u2e. .� �Loa�my to �ed.iun, .i 2y. egezazzon TO nwilm."c CESSPOOLS: NO (cesspool must be pumped as part of inspection)(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(yes or no): Comments(note condition of so11,signs of hydraulic failure,leyel of-ponding,condition of vegetation,etc.): r Ces�/�oo 2.s a'a not12ae PRIVY:NO (locate on site plan) M ' M Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.): l a.ivy_ t� not 2e�ent ' r Page 10 of 11 G Op...V•pLUNTA3t :ASSESSMIEN-TS orne ,.r1vSrEroN NO'F ' • 5��.LA�("-E'SE�AC�E��Cp �P.O•S��'8'�TEA�IhYSLEG��'3®��FORI� PAR' 5YS` EM `RON(4®ntinved) PropertX Address: 0 8 L h,_�o n.�l ?o a d o u.� a Owner:0u,inn /']o 0 Date of Inspection: SKETCH OF SE'WAGE'DISPOSA,L SYSTEM to at least.two P ovide a sketch of the sewage disposal system in ate where Sublic w4 a upp y eent x s.the bu er ilding. ben •Locate all wells within 100 feet.Loc p �\ 0J. f 10 Page I I of l l • -� •h OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20-R Owner: Qizi;rtn-.P1.on�_o Date of Inspection:.: 3�,/05: 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 plans on record - If checked,date of design plan reviewed: rLeh Observed site(abutting property/observation hole within 150 feet of SAS) yez Checked with local Board of Health-explain: az—gui.ft ca/Zd Checked with local excavators, installers-(attach documentation) ye-s Accessed USGS database-explain:hJU2 t 7own Bannz t a Cee.,rna.,ups You must describe how you established the high ground water elevation: Used ; Cape Cod Water Table Contours And P11h1 ; r Water 4nnn1► . and Well head protection areas man SPntPmher 1995 Water Resourses Office Cape Cad Commission - Top of n `Leaching Pit :cct �0 Groundwater:. .Feet Below Bottom of Pit High Groundwater Adjustment 1.8 h per Frimpter Method 3 i Therefore,the vertical separation distance between the bottom.. ' of the leaching pit andthe adjusted groundwater table is feet. aT� m 11 'I v•m+n'+r,—arrrr-zrras►ram,nm..srn*sasrrssnsr.•n-ritrerrrvtr**R,++*�'O7^�� 'TOWN OF BARNSTABLE BOARD OF HEALTH SUBSURFACE SEWAGE I)ISI'USA4 SYSTEM INSPECTION FORM - PART D CERTIFICATION Tea-r•:-::T--.nr.-•arnrnr+nnarrrn*rm�s,s+r-nr+-r.-v1v-%,rm-s.asnmrr HIN L'— S' -TYPZ OR PROPERTY INSPECTED STREET ADDRESS 20.8 Lewin Pond Road Cotu.i.t ASSESSORS MAP, BLaCCK AND PARCEL # 020- 1.32. Quinn Noose OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR Ro t eAt !a.o t in i COMPANY NAME ;ozel2h l l7acomlea''� Son Inc COMPANY ADDRESS �0___x_66 CQne2vc22e �la6h 02632 state LIP Sim ?o►n or City. COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 )190 - 1578 R CERTIFICATION STATEMENT I•. certify that I have personal°ly .inspeoted the sewage disposal. system at this address and that. tIi.e information reported is true , accurate., and omplete as of the time of , insp.ection . The inspection was performed and any recommendations regarding upgrade, .maintenance , and repair are consistent with my trainii,,g and experience in the proper function and maintenance of on- site sewage disposal systems. Check one: XXX Systeui PASSED The inspection which I have conducted has . not found any information which indicates that: the system fails to adequately protect .public health or the enviropment 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 wil.ich I have can d1Tcted has found that the system fails to Protect the jiublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspectio m, Date zcv Inspector Signature no copy of this certtfi.cation must b.e provided :to the .OWNER, the. BUYER where appli.ca.ble ) and the BOARD OF HEALTH. * If the inspection FAILED,, We owner or operator shall upgrade '.the system. within o'ne year of the date of the inspection, unless allowed or requ.i;red otherwise as provided in 3.110 CMR 15 , 306 .