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HomeMy WebLinkAbout0085 GROVE STREET - Health 85 Grove Street Hyannis P A = 310 163 , d i VIX t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposat System Form-Not for Voluntary Assessments 85 Grove St _- Property Address Premiere Asset Services, Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. Cityrrown state Tp Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information 1. Inspector_ Shawn Mcelroy Name of Inspector Shawn Mcelroy Enterprises Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number _ .6 � •�T B. Certification I certify that I have personally inspected the sewage disposal system at this address,and thaMe r; information reported below is true,accurate and complete as of the time of the' ` ' Ttie-inspt�tion was performed based on my training and experience in the proper function and main nance of on si_IAe sewage disposal systems I am:a.DEP approved system inspector pursuant to Se tion 15140 ofn Title 5(310 CMR 15.000)-The system ® Passes ❑ Conditionally Passes ❑ Fails (=1 Needs Further Evaluation by the Local Approving Authority M/ 1-30-08 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,,the inspector and the system:owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority- ""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. t5insp-08M Title 5 Official Inspection Fare Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 85 Grove St Property Address Premiere.Asset Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. Citylrowm State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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 is in good working order with no sign of back-up. 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. Answer yes, no or not determined;(Y„N,,ND)in the❑0,1 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 exfiltrati,on 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 yearn old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•08tG6 Title 5 Qfl-idAtnspectissn fonm Subsudace Sewage Dispasal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. City/Town State Zip Code Date of Inspection B. Certification (coot.) B) System Conditionally Passes(coat.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: i 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 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, r 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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is Hyannis MA 02601 1-30-08 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (coat.) C) Further Evaluation is Required by the Board of Health(coat.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`. Method used to determine distance: "* This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria 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 '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or El M 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 Q 0 tributary to a surface water supply. t5insp•08MB TWe 50 r lns t Fww__Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal)System Form Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 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 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`fifes¢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 ❑ ❑ the system is located in a nitrogen sensitive area(Interim wellhead Protection Area—IwPA)or a mapped Zone It 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. t5insp•08/06 Title 5 Officiatlnspection Foam Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. Cityrrown 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? El ® 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,opens 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)] t5insp•OWN if dte 5 01f5cfat Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name Information is required for Hyannis MA 02601 1-30-08 every page. Cityrrowm State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 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)): Sump pump? ❑ Yes ® No Last date of occupancy: 12-07 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsipersonsisq.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: Last date of occupancyluse: Date Other(describe): t5insp•08/06 Tig'e 5,0ffidal hispectioo:,Fomz_Subvztace Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Grove St Property Address Premiere.Asset Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑' Yes ® No If yes, volume pumped: gallon 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/Altemative 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): Approximate age of all components, date installed(if known)and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•08/06 Tide 5 O fieial.Wspectimr Form.Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System- Form Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset.Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ❑ cast iron 0 40 PVC a other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting evidence of leakage,etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: Cover on gradefeet 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: 8x8 Block cesspool Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle 60" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle WA How were dimensions determined? Tape t5insp•O&06 Trfffi S@Xreci�:lnspeciiort Form:Subsurface SeWap Disposal System•Page 9 of 15 Commonwealth of Massachusetts Tale 5 Official Inspection Form Subsurface sewage Disposal system Form-Not for Voluntary Assessments . 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet.ifivert,evidence of leakage,etc.): Tank in good condition with all baffles in place. Grease Trap pocate 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 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): t5insp•08/06 Title-,5 Official inspection,Form:Subsurface Sewage Disposal System•Page 10 of 15 r Commonwealth of Massachusetts lugTale 5 Official Inspection Form Subsurface Sewage Disposat System Form -Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02501 1-30-08 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(coat.) 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 Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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.): r Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order ❑ Yes ❑ No t5insp- Td e 5 Officrd kmpection Fm m Subsurface Smage Dsposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 official Inspection Dorm Subsurface Sewage Disposal:System Form Not for Voluntary Assessments, �.., 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 1-30-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number. ® leaching trenches number,length: 1-25'x4' ❑ 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.): Good condition with no sign of back-up. t5insp•011106 TWe 5 Official'Inspection Fome Sbsudface Swage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form_Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owners Name information is required for Hyannis MA 02601 1-30-08 every page. City/Town State Zip Corte Date of Inspection D. System Information (coat.) 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 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.): t5insp•08106 Td e 5 offieWt;mpeel[on;Fotcia;Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information is Hyannis MA 02601 1-30-08 required for y every page. CityrTown State Zip Code Date of inspection D. System Information (coat.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. s � U t5insp•Q81lIB Tft 5 Dtteda MWecfim F©m Sins Sewage D4asal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form_Not for Voluntary Assessments 85 Grove St Property Address Premiere Asset Services Owner Owner's Name information required r Hyannis MA 02601 1-30-08 e9 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 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 propertyfobservation 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: original documents show no water at 16'. t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �ptHE 1p� Regulatory Services BARNSTABM ; Thomas F. Geiler,Director 9Q ib `0� oA,F039. Public Health _Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations. contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. I V3 p c= COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF,,ENVIRONMENTAL AFFAIRS DEPARTMENT OFENVIRONMENTAL RECEIVM JUL 2 12003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION.FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM PART A CERTIFICATION Property Address: 85 Grove Street MAP � . Hyannis, MA Owner's Name: Al Muncherian PARCEL Owner's Address: Date of Inspection: - Name of Inspector:(please print) Wi 1 1 i am E_ . Robinson Sr. Company Name: . William E. Robinson Septic Service Mailing Address: P O-Box 1 089 Centerville MA Telephone Number: (_5081 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and.that the information reported. below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the.proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector.pursuant to Sec on 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: `'�„ �' .^� Date: 2-- O 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heattlilor DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit.the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 h r Page 2 of I 1 V LUNTARY ASSESSMENTS F O R O OFFICIAL INSPECTIO N FO RM -NOT _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSCTION FOP PE PART A CERTIFICATION (continued) Property Address: 85 Grov yannis MA • Owner. Al Muncherian Date of Inspection: a; Inspection Summary:,Check A,B,C,D or E/ALA S complete,all of Section D A. Sys m Passes: I have not found any information which indicates of evhat aluated d ary Of the e failure atederia below described in 310 CMR 15.303 or.in.310 CMR 15.304 exist.Any failure criteria n Comments: B. System Conditionally Passes: cribed in the One or more system components athe re replacement or repa'�r,�as approonal ved by she Board of Healthwill pass. rep iced.The system,upon completion of p Ans er yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please expl in. whether metal or not)is structurally; The septic tank is metal and ov oer 2r exfiltration or years old*or mtank failure septic e is nk(unmtnea System Will pass ins peeti n if the uns d,exhibits.substantial infiltrationseptic tank as approved by the Boar d of Health: exis ing tank is replaced with a complying ep +A al septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance ind' acing that the tank is less than 20 years old is available. N explain: backup or break out or high static water level m the distribution box due wbroken or sewa a if with Observation of g . P will as inspection o structed pipe(s) or due to a broken,settled or uneven distribution box.System p a roval of Board of Health):- are replaced broken pipe(s) P . obstruction is removed distribution box is leveled or replaced explain: in more than 4 times a year The sstem required pumping due to broken or obstructed p'rpe(s).The system will Y pas inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is nmovcd ND exp ain: b_ Page 3 of l l OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART`A CERTIFICATION(continued) Property Address: 85 Grove Street Hyannis, . MA Owner: Al Muncherian ........ . . . Date of Inspection: 7— —® C. Further Evaluation is Required by the Board of Health onditions exist which require further evaluation by the Board of Health in order to determine if the system is failin to protect public health,..safety or the environment. 1. S stem will pass unless Board of Health determines u accordance with 310 CMR.I5.303(1)(b),that the, s stem 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 0 feefof a bordering vegetated wetland or a salt marsh. 2. Sy tem 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 septu_tank and soil absorption system(SAS)and the.SAS is within 100 feet of a su face 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 front a rivate water supply well".Method used to determine distance "This system passes if the well water analysis,performed at DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and, the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. O her. 3 y Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION(continued) Property Address: 85 Grove S r_e_P a Hyannis Mn - Owner. Al Muncheria Date of Inspection: PP y D. ystem Failure Criteria applicable to al systems: _ : You ust indicate`yes"or"no"to each of the following for all inspections: Yes o _ Backup of sewage into facility or system component due to overloaded or clogged to a or cesspool the surface of the ground or surface waters du Discharge or ponding of effluent to e 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 a day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed p�pe(s):Number of times pumped • or privy is below high ground water elevation. Any portion of the,SAS,cesspool s within 100 feet of a surface water supply or tributary to a surface Any portion of cesspool or privy i water supply. y portion of a cesspool or privy is within a Zone 1 of a public well. — _ y,portion of a cesspool or privy is within 50 feet of a private water supply well. _ y 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, boratory,.for coliform bacteria and volatile organic compounds performed at a DEP certified laofamonta indicates that the well is,tree from pollution from that facility and the that n other failure cr nitrogen and nitrate nitrogen are is equal to or less than 5 m,provided are triggered.A copy of the analysis must be attached tothis form.] ( es/No)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. rge Systems: To a considered a large system the system must serve.a facility with a design flow of 10000 gpd to IS,000 You ust indicate either"yes"or"no"to each of the following: (The f lowing criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water Supply _ the system is within 200 feet of a tributary to a surface drinking water supply t system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Z ne 11 of a public water supply well " is Was a significant threat,or answered If you have swered yes to any question in Section E the system or of any large system considered a "yes"in Sect on D above the large system has failcd-I C owtt�oT operat significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The s ystem owner should contact the appropriate regional office of the Department. 4 Page 5 of i l OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'-- --' PART B ..: CHECKLIST Property Address: 85 Grove Street Hyannis, MA Owner:Al Muncherian Date of Inspection: 1-47-a'.3 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 2 — Were as built plans of the system obtained and examined?(If they were not available note as N/A) I/ — Was the facility or dwelling inspected for signs of sewage backup? V — Was the site inspected for signs of break out? �— Were all system components,excluding the SAS,located on site 7 r�Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems.? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no > /Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 ClAR 15.302(3)(b)) 5 Page 6 of I 1 ' OFFICIAL INSPECTION FORM—,-NOT FOR VOLUNTARY ASSESSMENTS f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: 85 Grove Street Hyannis, MA Owner: Al Muncherian Date of Inspection: /l-49­00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): DESIGN flow based on 310 CMA 15.203(for example: 110 gpd x N of 15cdrooms): G Number of current residents: Does residence have a garbage grinder(yes or no): ya Is laundry on a separate sewage system(yes or no):&g[if yes separate inspection required] Laundry system inspected(yes or no): A., Seasonal use:(yes or no):�ki Water meter readings,if available last 7 ears usage(god))-.. g , ( y g (gP )) ..,9/.01. 1 1"4,:9 0.0 . . . . Sump pump(yes or no):idiU 5/0 3 121 ,700 Last date of occupancy:: 7-9_0'0 COMMERCIA NDUSTRIA"L Type of estal nt: Design flow(base on 310 CMR 15.203): gpa.. Basis of design fl., (seats/persons/sqft,etc.): Grease trap prese t(yes or no):_ Industrial waste lding tank present(yes or no):_ Non-sanitaryw to discharged to the Title 5 system(yes or no): Water meter re ings,if available: Last date of oc upancy/user OTHER(describe): GENERAL INFORMATION Pumping Records �� Source of information: •��►h ,y 4- b4--k /Z,,6 io Was system pumped as pan of the Inspection(yes or no): If yes,volume pumped:)S� gallons--How was quantity pumped determined? 6 A, `,AU6/tL Reason for pumping: TYPE OF SYSTEM - _eptic 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) _Tight tank Attach a copy of the DEP approval _Other(describe): A a-- C) Q AJ G a e pe.4- G.• ?� c L 0 Approximate age of all components,date installed(if known)and source of information: z f Were sewage odors detected when arriving at the site(yes or no):� 6 Page 7 of I 1 OFFICIAL INSPECTION FORM=NOT-FOR-_VOLUNTARY ASSESSMENTS -. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ART C SYSTEM INFORMATION(continued);: Property Address: 85 Grove Street Hyannis, MA Owner:Al M unc i an Date of Inspection: 7—lq-03 BUILDING SEW R(locate on site plan) Depth below grade: Materials of cons ction `_cast iron _40 PVC,, other(explain): Distance from pr' ate water supply well or suction line: Comments(on ndition of joints,venting,evidence of leakage,etc.): SEPTIC TANK-,•—(locate on site plan) Depth below gra e; Material of cons ction: concrete_metal_fiberglass _polyethylene other(explain) If tank is metal list ge:_ Is age confirmed-by a Certificate of Compliance(yes or no):__(attach,a,copy of certificate) Dimensions: Sludge depth: Distance from top f sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top f scum to top of outlet tee or baffle: Distance from bo om of scum to bottom of outlet tee or baffle: How were dimen ions determined: Comments(on ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to ou et invert,evidence of leakage,etc.): o Div GREASE TRAP:_(locate on site plan) Depth below gra e:_ Material of cons ction:_concrete_metal fiberglass_polyethylene_other.= (explain): Dimensions: Scum thickness: Distance from to of scum to top of outlet tee or baffle: Distance from b ttom of scum to bottom of outlet tee or baffle: Date of last p ping. " Comments(on umping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to o tlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 { OFFICIAL INSPECTION FORM.—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM`INFORMATION(continued): PropertyAddress• 85 Grove St t • yannis MA _ _ - owner: Al Mu:n'c>herl am oInpe ction �Date - TI GHT or OLDIN G TANK' (tank must be pumped at time of inspection)(locate on site plan) Depth below de: g ___polyethylene Material o[cv struction: concrete. metal fiber lass other(explain): Dimensions: Capacity: allons . Design Flow: allons/day Alarm present yes or no): Alarm level: Alarm in working order(yes or no): Date of last p mping: Comments ondition of alarm and float switches,etc.): DISTRIBUTION OX: (if present must be opened)(locate on site plan) Depth of liquid lev I above outlet invert: Comments(note i box is level and distribution to outlets equal,any evidence of solids carryover,any evidence or.. leakage into or o t of box,etc.): PUMP CHAMBE (locate on site plan) Pumps in working rder(yes or no): Alarms in work-in order(yes or no): Comments(note ondition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 Grove Street HUannisi MA Owner: al DdilnAer; an Date of Inspection: —¢—O-3 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: Caching 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.): , CESSPOOLS: I/ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: / F- CO Depth—top of liquid to inlet invert: Depth of solids layer: S 8' Depth of scum layer:1— Dimensions of cesspool: l Materials of construction: 6/e c, Ae -5 Indication of groundwater inflow(yes or no):Zt.,O Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY- (locate on site plan) Materi s of construction: Dime ions: Dept of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of.vegetation,etc.): 9 Page 10 of 11 OFFICIAI,INSPECTION FORM—NOT FOR VOLUNTA Ry AS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F SESSME NTS PART C ORM SYSTEM INFORMATION(continued) Property Address: 85 Grove Street Hyannis, MA Owner: 41, nrt;;,,�herian Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 8 0 �J 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 85 Grove Street Hyannis, MA - Owner:Al Muncherian Date of Inspection: 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: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You in describe how you established the high ground water elevation: o "p 'M 1 I1 4 s r L6CATION OU d SEWAGE # VILLAGE_ dSLC,4/1 dS ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) fi�e" c� (size) �k NO. OF BEDROOMS a BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching'Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet f leaching facility) �-- Feet Furnished by J5Za�+ '4p5"el'o 4 <,e �.1.5. O � ray � � G � n �q S 1 Q \', �1 � i b n � } a � �; f -,. f - _ � TOWN OF BARNSTABLE LOCATION J5- 4942ZL 24 Si SEWAGE #15 15-W VILLAGE IIY/9.6011-S ASSESSOR'S MAP & LOT ic3 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY G's25 f:t '.�j.t D G.�SS.o�L o7c L 1 L LEACHING FACILITY: (type) 7",gG11 (size) a S -7' — NO. OF BEDROOMS R OR OWNER /P � ,W-5 .5 iieQ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility AC.9' 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 off lleaching facility Feet Furnished by Q a � � n � � � . �` `� � o = � " ' �, � i _s .. � y c� ''���� . . s. —� .- — 10 dd . d? CERTIFIED SEPTIC SYSTEM REPORT SUN 2 .d 0 1995 � N LOCATION 6 S � 85 GROVE ST. HYANNIS, MA MAP 310 PARCEL 164 LOT 18 PREPARED FOR �ELLF.� MR. JAMES SYKES, TRUSTEE 40 WILLIAMSBURG AVE . HARWICH, MA 02645 BUYER NONE AT PRESENT TIME PREPARED BY HILLIARD HILLER, JR. 41 MAPLE AVE CENTERVILLE, MA 02632 508-778-1472 e 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property YS 6kov6 67- 11X4A)"1S ^>Fd owner' s name 11-a. Date of -Inspection PART A CHECKLIST Check if the following have been done: t/ Pumping information was requested of the owner, occupant, and Board of Health. None 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. __Ailfl As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. tank manholeig were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. i 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential bz number of bedrooms O number of current residents _k,t2 garbage grinder, yes or no laundry connected to system, yes or no _A,t9 seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: &1'e"ey6,E 7�`,99 eFlarTiZ Last date of occupancy GENERAL INFORMATION Pumping records and source of information: N� System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system Single cesspool W/TH Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information : _. Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART E SYSTEM INFORMATION continued SEPTIC TANK: IVO (locate on site plan) depth below grade:_ material of construction: concrete metal FRP other(explain) dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) DISTRIBUTION BOX: kt-�, ( locate on site plan) depth of liquid level above outlet invert Comments: (,cote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) FRUMP CHAMBER: AZ) ( locate on site plan) pumps in working order, yes or no Comments : (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) r v 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : `/6S (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type Leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: ( mote condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) �'►;�;�;►�(�OI,S ( .locate on site plan) . number and configuration " depth-top of liquid to inlet invert depth of solids layer c10.pt� .h Of scum layer dimensions of cesspool _ __B '¢ �'i" ��FrU�� a �✓r� materials of construction indication of g.r.oundwater. inflow (cesspool must be pumped as part of inspection) Comments : (note condition of soil , signs of hydraulic failure, level' of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) rCEs Y4 lgvr o,� /��/ 'TS Pu�,o ,l'U4_ey TWo >Izwl eS —LE k'S 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, recommendations for maintenance or repairs, etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -- PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: 8S 64o4� Sig include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' //iSUri� FE rGE /S .PO.��/L L/.vE [7 GENE 00 $7,�D 4A,�: 7RCAC- I ` � Xk- ,guLKit P/9o� � O° gS G RovE 5 7 5TRF FT DEPTH TO GROUNDWATER /G. 8 depth to groundwater ` method of determination or approximation: 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? A/ Discharge or ponding of effluent to the surface of the ground or surface waters? Ufl _ Static liquid level in the distribution box above outlet invert? _/ Liquid depth in cesspool <601 below invert or available volume< 1/2 day flow? N Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? 1s any portion of the SAS, cesspool or privy: Al ._ below the high groundwater elevation? _ ZV within 50 feet of a surface water? _ X) . within. 100 feet of a surface water supply or tributary to a surface water supply? - IV within a Zone I of a public well? Al-/ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? - Al within 50 feet of a private water supply well? Al less than 1.00 feet but greater than 50 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 analysi, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrite nitrogen. y - t TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET. ADDRESS 57 ASSESSORS MAP , 49&= AND PARCEL # 3/0 //G 3 6 / OWNER' s NAME jl"?I�IZ5 5��s /•r'�sTCi� PART D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME COMPANY ADDRESS SOX �Sy Street Town or City State ZIP COMPANY TELEPHONE ( S FAX CERTIFICATION STATEMENT. I certify that I have personally inspected the sewage disposa-1 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: ' System 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 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 �/ ,c, Date 6x One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc