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HomeMy WebLinkAbout0081 OLD KINGS ROAD - Health 81 OLD KINGS ROAD, COTUIT A�022 002 1 f t 1' TOWN OF BARNSTABLE �7 LOCATION , / 0 9 AQ SEWAGE #X,00 VILLAGE C Q T Ulr ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. _Jr/7 /1d A CCa Ail 9 et? r 5; Q N SEPTIC TANK CAPACITY Z ,-o O Ale cd LEACHING FACILITY: (type) ef7 n Zo. (size) l O 470 NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 A on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist r within 300 feet of leaching facility) Feet Furnished by PJ l / TOWN OF BARNSTABLE LotATION /�l�l d S D�i9� VILLAGE �D�1� T, /� �§ ASSESSOR'S MAP& LOT NAME&PHONE NO. h?her 1icC SEPTIC TANK CAPACITY � �' LEACHING FACILITY: (type)��'X t�` (size) NO.OF BEDROOMS BUILDER-OR OWNER PE : `v�' �.0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 leachin fa ' 'ty) Feet i Furnished b . f :it idOs . No. 637d s. Fee$ 50. 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for ;Digpozal *p6tem Construction Permit Application for a Permit to Construct�X)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 81 O 1 d Kings WE?ad Owner's Name,Address and Tel.No. 4 2 8—9 9 7 0 Cotuit,Mass. 02635 Kieth Markoski ,. ssessor'sMap/Parcel 81 Old Kings My Cotuit,Mass.02635 Installer's Name,Address,and Tel.No.5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass.02632 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy sand to fine sand Nature of Repairs or Alterations(Answer when applicable) Omitting main cesspool. Installing 1500 gallon septic tank and one distribution box to the existing leaching pit. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by this.X Signed Date d of Health. J, 10/18/00 Application Approved by Date /0 Application Disapproved for the following reasons Permit No. �� Z— Date Issued TOWN OF BARNSTABLE y LOCATION SEWAGE #Z 1,00 613 VILLAGE C Q T !T ASSESSOR'S MAP & LOTPU 5 INSTALLER'S NAME&PHONE NO. ,- iit SEPTIC TANK CAPACITY ,ro O Ale cd LEACHING FACILITY: (size) /.O 00 NO. OF BEDROOMS ,- o - BUILDER OR OWNER PERMITDATE: COMPLLANCE 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 _ • Q it x'f J" \ �\ y I. \��_. Fee$ 5 0.0 0 i � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes 'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Mitpont 6potem Construction Permit Application for a Permit to Construct�X)Repair( )Upgrade( )Abandon( ) ElComplete System El individual Components Location Address or Lot No. 81 O 1 d Kings Nekird Owner's Name,Address and Tel.No. 4 2 8—9 9 7 0 Cotuit,Mass. 02635 Kieth Markoski Assessor'sMap/Parel O ©o 81 Old Kings MY Cotuit,Mass.02635 r. Installer's Name,Address,and Tel.No.6 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 03635 Box 66 Centerville,Mass.02632 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date "Title 11 Size of Septic Tank Type of S.A.S. Description of Soil Loamy sand to fine sand Nature of Repairs or Alterations(Answer when applicable) Omitting main cesspool. Installing 1500 gallon septic tank and one distribution box to the existing leaching pit. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system F in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu'd by this o d of Health. Signed R. ..PY Date 10/18/00 Application Approved by Date Application Disapproved for the following reasons Permit No. 3 Z— ;Date Issued � THE COMMONWEALTH OF MASSACHUSETTS �juk BARNSTABLE, MASSACHUSETTS, Certificate of Compliance try THIS`IS CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired X Upgraded( ) +' Abandoned( b J.P.Macomber & Son Inc, at 81 ,Qll as Road Cotuit Ms--aG • has been constructed in accordance with the'pr$ov lions of itle 5 and the for Disposal System Construction Permit No L -6 3 Z dated O �< r Installer �P.MAi tuber & Son~,:Inc. Designer J.P.Macomber &X Son Inc. %"�'i The issuance of this petmit shall nat be co strued as a guarantee that the system will function ashes ig ead. � fDate ':t��> Inspector / /1 � �I ra'�i4rs �) rs T J' W `No `6 w�, t. g r Fee THE COMMONWEALTH OF MASSACHUSETTS „ ;f PUBLIC HEALTH DIVISION - BARNSTABLEJOASSACHUSETTS ," . e t pogaI *p5tem Con5tructtori ermtt sk *. , XY . Permission IsFherebygratfted to`C,onstrucf( )Repair �Upgrade( )Abandon a+ i Systerr[ ocateilt Old' n s Road Cotuit Mass x w Vl 14 and as described inwthe above Apphcataon for Disposal System Construction Permit. The applicant recognizes.his/her duty to I`. comply wit`li Title 5 and the following local provisions or special conditions. - �k Provided (�,oii traction must be coaj.16ed,within three years of the date of thi a t. '. "Date: �; "r /7i,9vv- Approved by 0 aLta r s,.y#� L 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) Joseph P.Macomber Jr. hereby certify that the application for disposal works construction permit signed by me dated 10/19/0 0 concerning the property located at 81 Old Kings Road Cotuit,Mass. meets all of the following criteria: F✓ The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling, ✓/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ✓ re are no wedands within 100 feet of the proposed septic system There are no private wells within ISO feet of the proposed septic system •/There is no increase in flow and/or change in use proposed •� There are no variances requested or needed. •� The bottom of the proposed leaching facility will -gLbc located less than five feet above the maximum adjusted groundwater table elevation, (Adjust the groundwater table using the Frimptor method when applicable] if the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will M be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevadon(using GIS information) y B) G.W. Elcvadon '� 0 +the MAX. High G.W. Adjustment.3-�Z' _ 3 D=RENCE BETWEEN A and B SIGNED�roposed DATE: 10/18/00 [Sketch plan of system on back]. q:health folder.cert e t.R �. . t ! .. / �;..� ', ,� .� __ /` t V i (0 DATE: 12/2/96 _ PROPERTY ADDRESS: 81 Old -Kings Road . Cotuit,Mass . fyf DEC 02635 .. / - r r._ On the above date, I Inspected the septic system at the above address: This system consists of the following: 1 . 1-61x8' block cesspool. 2. 1- 81x7'. precast leaching pit. Based on my Insoaetlon, I certify the following conditions: 1 . This is not a title five septic system. 2. The system is dry. •3. Cesspool has seroius root intrusion. 4. Septic system is in working order at the present. 5. If Root intrusion worsens. I would rec: ,replacement of the cesspool with a 1500 gallon septic tank. SIGNATURE: Name:-J. P .Macomber Jr., i Company:_,J. P_MacoMber & Son- -Inc . - Address:_-Beac-bg-----= ---,-- __Centervi11e , Mass__02632 Phone: ---50.8.z7_75.-,3338------- - ' THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ESEN P. MACO�RBER & SON, INC. TankrCeslpoolrLeschf leId6 Pumped L Installed Town Sewer Connections ox 66' Centerville, MA 02632-0066 775-3338 775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of environmental Protection Trudy Cox* 8--ly :� .. David B. Struhs U.Go i;, Carrvnhalorwr s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddreaa: 81 Old Kings Road Cotuit,Mass Address; ofOwner. Date of luspection: 1 2/2/96 (If different) Namecrinspector. Joseph P.Macomber Jr. Company Name,Address and Telephone Number. JppggP.(M��ajjcoo�mbeer ��& Son Inc. B T FICATION9TA7'EMENTrMat3s. 02632 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 inspection. The inspection was performed based on any training and experience in the proper function and maintenance of on-site as disposal systems. The system: s 7' Conditionally Passes — Needs Further Evaluation By the Local Approving Authority _ Fails laspectoes Signature: Date: The S7eum Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner-u-d copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B. C, or D: Al SYSTEM PASSES: — ' have not found any information which indicates that the system violates any of the failure criteria as defined in 310 ChM 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: ,41y One or more eysum components used to be replaced or repaired. The system, upon completion of the replacement or repair, pasties inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If'not determined', explain why not) lVat' l The septic tank is metal, cra:ked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. 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Owner. Atty;John Conathan Date of Inspection:12/2 9 6 DI SYSTEM FAILS: • h I have determined that the system violates on•or more of the following failure criteria as defined in 310 CMR 16.303. Ths basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. A20 Discharge or ponding of effluent to the surface of the ground or surfaw waters due to an overloaded or clogged SAS or cesspool. d,b4'C Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth obis leas than 6"below invert or available volume is Is"than W day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. (� Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a oesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARG E SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)Lad the systam is a significant threat to public health Lad safety and the environment because one or more of the following conditions exist: ,Qlfi the systam 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 ,VA 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) The owner or operator of any such system shall bring the system and facility into Rill complisnw with the groundwater treatmsnt program requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for Anther information.. I v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 81 Old Kings Road Cotuit,Mass . Owner. Atty: John Conathan Date of Iaspeotlon: 1 2/2/9 6 e Check if the following have been done: ` 2pumping information was requested of the owner, occupant, and Board of Health. zone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N built plans have been obtained and examined. Note if they are not available with N/A -L/Ths facility or dwelling was inspected for signs of sewage back-up. , The system does not receive non-sanitary or industrial waste flow -- ,LThe site was inspected for signs of breakout. ,system components,�e:cludi"Soil Absorption Systems, have been located on the site. A104-1e,The ie`ptic tanl maahcles were uncovered,opened,and the interior of the septic tank was inspected for condition of baMes or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on existing information or ap roxi hated by non-intrusive methods. he facility owner(and occupants, if different from owner)were provided with p information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 J , SUDSLUFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Aclst�,� 81 Old Kings Road Cotuit,Mass . owner. Atty; John Conathan Dak or In,po4jti t.: 1 2/2/96 FLOW CONDITIONS RPSIDENTL L• J Docgn Bow: lions�^t7/�y Number of bedrooms:- Number of current rwidenu:4; Carba,a-v grinder(yw or no):_ LLundry connected to eyeum (yw or no):\be Seaw:a) ue (yei cr no), Water msur readings, if available: Last dsu of oc"pancy:� COMMERCIAL/TNDUSTRIAL- Type of ertabL.shatent: kW Daeb-n flow: AM p1lons/day Crease trap present: VW or not —)q Ladustrial Waste Holding Taak present: (yes or nOALA Non•saaitary waste discharged to the Title 5 rystom: tyes or no)'Q9 Water meter reading, U available: Lan date of oocupa.nry: OTHER (Describe) VV9 _ Lan date of occupancy: GENERAL INFORMATION PUMPING RECORDS d so of' urination: W'141c r��-gip 1ae� Sytum pumped as part of inspection (yea or 110) Q Cy$j�ys7 � U yu, volume pumped: 4IJ9 >auutts Reason for ➢UM➢45 yA TYPE OF SYSTEM Septic to 3Udistribution box/sod absorption a)eum � _L Overflow coupwl ArV'C'HgX �7. r _ 16 Privy -�d Shared ryrtem (yes or no)(if yes, attach previous inspection records, if any) _IV Other(ezplr..ia) r APP 0,�TE AGE of 4 oomponenu ir, date -iUd1W (if lutown) and souma of information: 1 Soware odors r.Atsvtsvl Wti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: 81 Old Kings Road Cotuit,Mass . Owner: Atty; John Conathan Date of Inspection:12/2/96 SEPTIC TANK:A(/P . (locate on site plan) Depth below grade:lu Material of construction: //9concrete _metal _FRP —other(explain) Dimensions: Sludge depth:_ L Distance from top of sludge to bottom of outlet tee or baffle: / L Scum thickness:_ _,4.14 Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle._A/ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural ,riry, evidence of leakage, etc.) Septic'' tank is not present. IL GREASE TRAP. IOVO, (locate on site plan) Depth below grade:,4_4 Material of consmlrti6n;0?zoncrete _metal _FRP —other(explain) Dimensions; ti Scum thickness: Distance from top v i scum to top of outlet tee or baffle: 441 [distance from bottom nl rilm to bottom of outlet tee or b5hte ��- Comments: (recommendation for pumping, condi—rt of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, ettj.�Qrease trap is not present. s (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) prvpertyAddreas: 81 Old Kings Road Cotuit,Mass . Owner, Atty; John Conathan Date of Inspection: 12/2/9 6 TIGHT OR HOLDING TANK-,a&,fi (bcate on site plan) e Depth below grade:. Material of constructio;,gconcrete_metal_FRP—other(explain) - Dimensions: .t4 Gpecity as Design aoa: ona/day Alarm level: A) Comments: (condition of inlet tee,condition of alarm sad float switches, etc.) Tight nr holing tank nnt. nragant. DISTRIBUTION BOX:_40ti'L (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) Distribution box .is not present PUMP CRAMBER:�02C; (locate on site plan) Pumps in working order.(yes or no)A�9 Comments: (note condition of p chamber,condition of pumps Lad appurtenances, etc.) Pump champber is not present (revised 11/03/95) T ": •' U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addre" 81 Old Kings Road C o t u i t,Mass . owner. Atty;John Conathan Date of Inspection: 1 2/2/9 6 SOIL ABSORPTION SYSTEM(sAak-Z Qocats an site plan,if posssbls;szcavation not squired,but may be apprmimated by non-intrusive methods) e If not determined to be present,a rplain. 1"ciblo pits,number_ Type leschin chambers,number. lWhia�galleries,number: leaehl trenches,number,)eagth l.schiag fields,number,dims ns: overflow cesspool, number. Comments: (note condition of soil, s' of hydraulic failure, level of ponds 1, condition of vegetation,stcJ Sand•No signs of h Traulic failure • o si ns of ondin vegetation is normal . Leaching pit is dry and is used as an overflow off 0 a raacr�nnl _ CESSPOOIA—Z (locate on site plan) Number and configuration: Depth-top of liquid to inlet Depth of solids layer Depth of scum]slyer. Dimensions of oeaspool Materials of construction: eXr- Indicatian of groundwater._ .0,4A Ze_ inflow(cesspool must be pumped as part of inspection) .e iK k/ Did not pump. No signs of wat.ar t.a hl a Comments: (note condition of soil,signs of hydraulic failure,level of pondin&condition of vegetation,etc.) Sand ;No signs of hydraulic failure •No signs of pondin • All vegetation is normal reSQpnnl is dry and nets as s sa tin tank with a 1000 gallon leaching pit as an overflow. PRIVY: (locate on site plan) Materials of oonstructia . N/A Dimensions N/A Depth of solids:_V A Comments:(note condition of soil, 8�of hydraulic failure,level of pondin&condition of vegetation,etc) Privy is not present (revised 11/03/95)• g 1;J�,jURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .1201,A PART 8 SYSTEM INFORMATION continued SKETCH OF SENACE L :SPOSAL SYSTEM: include ties to at least two pert *f Qegjdanj#arks or benchmarks locate all wells within 100 ' Cotuit ter Company 428- 7 1 \ . Is • i DEPTH TO GROUNDWATER depth to groundwater r+pth_od of determin ion or approximatioz: No water::�n'cbunt- .w s' 'installed as an overflow om- the cessPoo-1 ...:.. ..._ -� .. SJ r. E CO,'NIMONWEAL H OF MASSACHUSETTS DF-YARUNIENN-J" OF ENVIRONMENTAL, PR.0TECTJ-(-)`,- BE Ir r KNOWN THAT Joseph P. Macomber., Jr. Has satisfied the Department' s qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protectic).j . June 8, 1995 ACLIng Director of the ion of Water Pollution (—Jr,', �]•1T.TlA.—n.7-�r--.•n�zrn. mrnT.rls-nrtssrrrr+�rrlrr!rT►rT.RA'1RTl nern7rT1I�J7@re7' Tmrrll—r-...-.,r—...' I TOWN OF Barnstable BOARD OF HEALTH l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I �� �^•rn�•..•c.r-rai►-.�rn+Tr+n•rt.rn r��+esrrtaTrrrs�*tirrnntanrtvr�Ttrnrarn��r�w-sr� nen ..—re-'- r•„ •-..A -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS 81 Old Kinas Road Cotuit.Mass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Atty; John Conathan PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME J.P.Macomber & -'8'on Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Tovn or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 w CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection.. The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXXXXXXX ystem PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to Protect the public Health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 12/2,/96 s�.rsr�zr One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. w If the inspection FAILED, the owner or"'o' erator shall up grade pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc L O C A T ION S E ,AGE PERMIT NO. VILLAGE INSTALLER'S ME i ADDRESS i ti OR OWNER DATE PERMIT ISSUED lb-16 Y'0 DATE COMPLIANCE ISSUED / 6 r y.-. ,, ,� ~ --�.�- �� 1 � / , � 4 �� � � .�.-