HomeMy WebLinkAbout0018 AGAWAM ROAD - Health l
18 Agawam Road
Marstons Mills P
--— A = 043 007018
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' SEWAGE INSPECT��1�
LCKATION Agawam Road j�w((yy11�� DATE 5129103
VII.LAGE Plat,61-on,6 PlILL, Nas,s. ASSESSOR'S MAP & LOT e 1�
-INSPECTOR jo.6eRh P. Placomge2 J2.
SEPTIC TANK CAPAC=I 5 n n yl, a -a Q A = n Y
LEACHING FACILITY: (type)2-6 'X4 ' P i-t,6 (size) 3000ga eion.6
NO. OF BEDROOMS 4
BUILDER OR OY/NERL-i.6a blood
OWNER MAILING ADDRESS
-Same
TAarE; n s
� P2
On
DAT E:5/29/03
PROPERTY ADDRESS:18 Agawam Road
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On the above date, I inspected the septic system at the above address.
This system consists of the following:
1. 1- 1500 ga2ion aepi is tank.
2. 1-Di.3ta.iPut.ion Sox,
3. 2-600 gaP2on p/Lecaet Peach.ing p.ita. RECEIVED
Based on my inspection, I certify the following conditions:
4. 7h.i.e .i.e a t.it.Pe live zept.ic -6yzte, (78 Code) JUN 0 4 2003
5. The zept.ic zyztem .ie .in paopea woak.ing oadea
at the paezent time. TOWN OF BARNSTABLE
6. The aept.ic tank ehou.Pd Pe pumped eveay 2-3 geaaz. HEALTH DEPT.
SIGNATURE:1'
Name:-JP_ Macomber Jr_______
Company: Joseeh_P. Macomber_& Son , Inc .
Address: Box 66
Centerville , Ma . 02632-0066
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Phone:- 508-775-3338
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THIS CERTIFICATION DOES NOT CONSTITUTE1-A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachf lelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,i
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 18 Rgawam Road
Maz,3ton3 Niiiz, Nazz
Owner's Name: Li,6a Qood
Owner's Address: �Cr,mg
Date of Inspection: 5129103
Name of Inspector: (please print)I o.6e 12 h /). (7acom9e4 Ia.
Company Name: J. P. Nacom ea & Son Inc.
Mailing Address: Rox hh ( vrztva�iP�e, l'la��. 02632
Telephone Number: 5 0 8-7 7 5-3 3 3 8
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails �k
Inspector's Signature: Date:
The system inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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 I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Agawam Road
CLlF.6 orz.6 .c -s, Plazz
Owner: L.i,3a tdood
Date of lt1 ection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D J1
A. System Passes: t
I have not found any information which indicates that any of the failuracAter))'a described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are:indicate elow.
Comments: �l
The 16eRt.ic zyztem .iz .in pao/zea wozk.iny p2cLe`
e�serzt t tme
r I
4 i
B. System Conditionally Passes:
w& 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 for the following statements. if"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally'
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A:metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
A2L2 Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
.*VD 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:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 Acgawam /toad
Owner:L.i.s a Yo o d
Date of Inspection: 5/,?9/0 3
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:
4 Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
,f 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.
-06 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
etJ0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
!�D The system has a septic tank and SAS and the SAS is less than 10A feet but 5 feet or more from a
tance L
private water supply well". Method used to determine dis ^/
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 A awam Road
a2h t 0n, a,5,3.
OWner:L-i.ba blood
Date of Inspection: 5/29/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ Y/ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
Zlogged SAS or cesspool
static liquid level in t e distribution box above outlet invert due to an overloaded or clogged SAS or
/cesspool d., _0orS
✓ squid depth in speed is less than 6"below invert or available volume is less than 1/2 day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
f times pumped�.
j /Any portion of the SAS,cesspool or privy is below high ground water elevation.
v Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
PAny 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,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
.Gly (Yes/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. 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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no 7
the system is within 400 feet of a surface drinking water supply
A-/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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART $
CHECKLIST
Property Address: 78 Agawam Road
aT6 Z onh 77.c .6, u,s,s.
Owner: Li.6a .6ho,cL
Date of Inspection: Uj
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 ?
v 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?
v _ Was the site inspected for signs of break out?
Y — Were all system components,Acluding the SAS, located on site ?
✓ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the ffles 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 n
/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(3)(b))
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 18 Agawam Road
a2.6 ons
Owner: L i,3a G)o o
Date of Inspection: 5/2 9/0 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):__y_ Number of bedrooms(actual): /�,(��
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): X--yyl� aAt'
Number of current residents:_1
Does residence have a garbage grinder(yes or no): dk
Is laundry on a separate sewage system yes or no):,& [if yes separate inspection required]
Laundry system inspected(yes or no):?tL,
Seasonal use: (yes or no): .00
Water meter readings, if available(last 2 years usage(gpd)):200I= 1 14, 000 ga.P.Pon,=312. 3 3 9/1 D
Sump pump(yes or no):All 2002= 121, 000 ga eion.3=3 31. 51 gPD
Last date of occupancy,
COMMERCIAL NDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): god
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):,d2�Industrial waste holding tank present(yes or no):/Iy
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available: /9
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):,"
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_✓Septic tank,distribution box,soil absorption system
d Single cesspool
Overflow cesspool
Privy
Q Shared system(yes or no)(if yes,attach previous inspection records, if any)
a Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
i)b Tight tank 't Attach a copy of the DEP approval
4/6 Other(describe):
Ap oximate a_ee of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):/1�d
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Agawam Road
Nan.stons 'Plie_Rs, glass.
Owner: Lisa IJood
Date of Inspection: 5129103
BUILDING SEWER(locate on site plan)
N
Depth below grade: //
Materials of construction: cast iron t/40 PVCL!/Qother(explain):
Distance from private water supply well or suction line:/dot
Comments(on condition of joints, venting, evidence of leakage, etc.):
jo.intz a121ea2 t-ight No evidence o4 .eeakage The system .is
vented th2ough the house vents.
SEPTIC TANK:4 (locate on site plan) /Pe)(�0,4 elf
Depth below grade:
Material of construction: •%oncrete eJemetaW,0 fiberglass.r✓O polyethylene
/Vd other(explain)
If tank is metal list age:AI Is age confurtted by a Certificate of Compliance(yes or no)i!//P (attach a copy of
certificate) > /
Dimensions:/e6���.CY' ��Pf�rY�6 677�/5.��
Sludge depth: 6k —
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:/—Pd'1"z—
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffl
How.were dimensions determined:Z&Ayf/'i
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
10ttytp .the .tank Q ozU�yeaA.3 Tn.eet & out eet tees ate .in place.
The Yank d,s AtR irtiinl�
a0U 6o14 / and howl no evidence 61
leakage. The .e.iqu.id eeve2 at the out.eet .inve zt . .is 51"
GREASE TRAH14(aocate on site plan)
Depth below grade:.(/4
Material of construction, concrete,0metaLVAfiberglass rQpolyethylene-C14other
(explain): IV-4
Dimensions: 11>)4
Scum thickness: le
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: A],¢
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
infir'68 `4Clan ; A nn f�n4ahen
7
Page 8 of 11
OFFICIAL INSPECT. . ' FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE S1 AGE DISPOSA,t, SYSTEM INSPECTION FORM
PART C
.S. TEM INFORMATION(continued)
Property Address: _ 18 Agawam Road
Owner:Liza Qood
Date of Inspection: 5%29/03
TIGHT or HOLDING TANKA&Z ink must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: 4)14
Material of construction:. concr. metal Vlf fiberglass polyethylene 414 other(explain):
AIX
Dimensions:
Capacity: Am 2 s
Design Flow: g: s/day
Alarm present(yes or no):
Alarm level: 4)4 Alarm in wo: order(yes or no): A.;f—
Date of last pumping:
Comments(condition of alarm and f switches, etc.):
7yht nn diaa rnkb aae not Raezen4.
DISTRIBUTION BOX: Zif P. t must be opened)(locate on site plan)
Depth of liquid level above outlet in .Ud
Comments(note if box is level and C ibution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
I i.AlIzIQLtion Sox haz two 2ateaaiz. No evidence o e eoiidz
r0.nn4� ovPn. NO v.idenee o,,' .Pe kage in o o—T ou o e ox.
PUMP CHAMBER(locate a. to plan)
Pumps in working order(yes or no): Ali
Alarms in working order(yes or no): 4.74
Comments (note condition of pump .ber, condition of pumps and appurtenances, etc.):
l014J47 nl•r-0— ; A nnf 1?2P_.SPnY .
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:78 Agawam Road
Naazione Mi-ei.s Plazz.
Owner: Liza ldoo
5-27
Date of Inspection: 5129TF3
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
2-600 ya2.Pon /2necazt ieachinq pite12'X4 '
Type leaching pits, number:
leaching chambers,number: O
leaching galleries,number: O
leaching trenches,number, length:
leaching fields,number, dimensions:
Z55 overflow cesspool, number: a r
4Z innovative/alternative system Type/name of technology:5;"'X''B rive 25 �7
Comments(note condition of soil, signs of hydraulic failure, level of ponding;damp soil,'con�dition of vegetation,
etc.):
Loam nand to medium 1.iize .6and. No zi nz o f hydAauiie /aiivae oa
aoad-ina Sii ate dau Vegetation i.s noltmci #1 Rit wa' e wa e2
.cis 5" gePow .enveat 12il?e #2-1?it ins 3 7" ge�ow the .tnve2t /?..fie.
CESSPOOLSCZi,k,(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 laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cea,612oo z ate not /22ezent.
PRIYYA& (locate on site plan)
Materials of construction:
Dimensions:_ M
Depth of solids: I&W
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
Page 10 o.f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properry Address: 18 Aga_wam Roorl
¢13-s.
Owner. L.i,6a 07o ,
Date of laspectioo: 5129103
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.
m Ro (1'1a(5Jw S
� PZ
/ �p
10
Page 11 of 1 I
OFFICIAL, INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Agawam /load
Na2etorae I.i4 a haze.
OWner:Liza Oood
Date of Inspection: 5/2 9/03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
nn^^ /
Estimated depth to ground water `ZC! feet
Please indicate(check)all methods used to determine the high ground water elevation:
Nam_Obtained from system design plans on record-if checked,date of design plan reviewed: NA
qES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain:
[IES Checked with local excavators, installers-(attach documentation)
qj_�Accessed USGSdatabase-explain:.h.ttR://town. ga.,znz.tatie. mu, ua.
You must describe how you established the high ground water elevation:
1Leed: Gah Lei
Need: LISGc . eta e matte 992.
U e e d: U S G S,,�e e k t��r --&to x, �-6L61.61-1 /2 et--e-� —A'ftftarma_ 'rrrrrg J o ey/Z Qzrrrd—
Leaching
Pit /-�9�
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Fnmpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is ��
feet.
11
yy rrnr-..-nr•rR�.-'r-srnrmr•nmrrr-nrta+n�mmrnr++�er+.►n+Rn eern�u�rt�n�s .. �I
TOWN OF /3a zn stag.fe BOARD OF HEALTH
0 SUIISURFACF 3EWACF DISPOSAL SYSTEM INSPECTION� FORM - PART D •- CERTIFICATION I
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 18 Agawam Road Naaztonz
ASSESSORS MAP, BLOCK AND PARCEL # 41 r-D!
OWNER' s NAME L�i,3a Oood .
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & Sdfi ' Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or City S t a t 9 LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 506 ) 790 _ 1578
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
omplete 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 :
_y 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 sectio» of
this form ,
System FAILED* \
The inspection w)Iic)I I have con tcted has found that the system fails to
Protect the public healt)i and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this, inspection f rm .
Inspector Signature JW
a � Date cJ=
copy of this ctification must be provided to the OWNER, the BUYER
and
where aPplicable ) and the BOARD OF HEALTII.
* It the inspection FAILED, the owner or..hoperator shall to
ayete
within one year of the date of the inspection , unless allowed dorthe requiredm
otherwise as provided in 3.10 ChIR 15 . 306 ,
partd . doc
a:
_��zegc 1C of 1
OFFICI?.L INSPECTION FORM — NOT FOR VOLL'NTA.RY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
" PART C
7' SYSTEM INFORMATION
4, (co:,tinued�
' , 1
PropertyAddrtss• 98 A oaw¢,g
OwDer: L L/6Q
D�tr of lcsprction: �i 2q/0�
SKETCH OF SEWAGE DISPOSAL SYSTEM
?tov,de a sketch of the sewage disposal system including tics to at Least two permanent reference landmarks or
bcnchm rks. Locate all wells within 100 feet. Locate where publie.,water supply enters the building.
A o t,;a m
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34 4.s
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3.44 24.a 15:0
L. OT -25 . LOT LOT 23 .
24 co
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—OOD ZONE: C 54. 0
S. ZONE: RF AGAWAM ROAD
FOVNPATLON CZRTZFICA't'IOrt
D UJN MARSTONS MILLS PLAN REF. 426-43
ATE 8/29/87 SCALE 401 ELEVATION
RE5Y CERTIFY THAT THE ABOVE
INDATION 15 LOCATED ON AItl.4EE Su.RVE Lj
GROUND AS SHOWN, AND �1�� Of y GO1tSLCLTaYtTS
P05ITION DOES
VFORM TO "THE ZON.INZ: TAMA.
J SET �CK REc�c1ZREMENT v ?O RAsp$1-Rrty E3 LN.
BARNSTAB .E No.3 � CAd`,t ARST'O!q S N1 ILLS M A
SU Q Z(c4cQ
�•, f AND RD
Ul- A. M&RZTHE 3 R•P.L.S.
TOWN OF BARNSTABLE
LOCATION Ae —AA�N✓�—,ea SEWAGE #
VILLAGE,e1� , " e&��ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)/-L!9� � ' (size)
NO.OF BEDROOMS
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 of lea ng fac' 'ty) Feet
Furnished by +
AY1"11f
no
;J
DATE: 6/3/99
PROPERTY ADDRESS:
-----------------------
-- 1-B
_- Marstons Mills, Ma.
c�
On the above date, I inspected the septic system at th �' ove �'�s.
This system consists of the following: � J U N 9 1999 �
1 . 1 -1500 gallon septic tank =V=310111
2. 1 -4 ' leaching pit 1=87L
3. Distribution box d)
Based on my inspection, I certify the following conditions: d
g
4 . This is a title five septic system. ( 78;. Code )
5. ,The septic system is in proper working order
at the present time . U 4/ 3 a0 ?0 / ?
6 , Pumped tank at time of inspection .
7 . Pit has 4 ' of stone all around .Waste ater is
44* below the invert pipe . /
SIGNATURE:2
Name:_J_P_ Macomber Jr____-_-
Company: Joseph_P. Macomber_& Son , Inc .
Address: Box 66
--------------------
Centerville , Ma. 02632-0066
--------------------
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-LeachfleIds
Pumped &,Installed
Town Sewer Connections
P.O.'Box 66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY COX
Secreta.•
ARGEO PAUL CELLUCCI DAvID B. STRUr i
Governor Corr ss:on:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Addr".&:1 8 Agawam Rd. Marstons Name of owner Lisa Wood
Mills Addrass of ownar: 18 Agawam Road
Data of inspection: 6/3/9 9 r, Q6/J,� Ir � Marstons Mills
Name of Inspector:(Please Pn"
I am s DEP approved system Inspector pursuant to S�tion 15.340 of Trio 5 (310 CMR 15.000)
company Names7ose h P. Macomber & SOn Inc
MaMngAddrasa$nX 66, Centerviiie, Ma. 632-0066
TiWeph, @Number: _908-775_3338
CERTIFICATION STATEMENT
I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below is true. accurata
and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and
maintenance of on•s_itesewage disposal systems. The system:
es
Y Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Sigrurrura: . / Date:
The System Inspec or shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)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 otr£nvironmenial Protection. The original should be sent to v-m
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
i
revised 9/2/98 Page Iof11
Pmled on Recycled Pipe,
w
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 Agawam Road, Marstons Mills
O1N1ef: Lisa Wood
Data of Inspection:6/3/9 9
INSPECTION SUMMARY: Check A, B, C, of D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
VOne 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.
Indicate yes, no,or not determined(Y, N, or NO). Describe basis of determination In all instances. If "not determined", explain why not.
The septic tank Is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)Indicating that the tank was Installed within twenty (20)years prior to the date of the Inspection; or
the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiluation, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
gyp, distribution box is levelled or replaced
" The system required pumping-snore than-lourtimes to yeardue to broken or vtrstructed pipe(s). The system willyass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98
Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirxiod)
Propx Address: 18 Agawam Road, Marstons Mills
Owner: Lisa Wood
04U of ma`s«': 6/3/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Condidons exist which require further evaluation by-the Board of Health In order to datermine If the system Is felling to protect the
public health, safety end the environment.
1) SYSTE3.1 WILL PASS UNLESS BOARD OF HEALTH DETERJAINES W ACCORDANCE WITH 310 CI.IR 16.303 (1)(b) THAT THE SY!
LS NOT FUNCTIONINO W A WANKER WWCKYALLPRQIECT THE PUBUC HEALTH.AND SAFETY AND TH—E D%,dSOK1.c —
W Cesspool or prlvy Is within 60 foetcf suriaca water
Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FALL UNLESS THE BOARD OF HEALTH(AND PUBUC WATER SUPPLIER. IF ANY)DETEP-MINES THAT THE SYSTEI i
FUNCTIONINO IN A I.IANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONMEKT:
�LA The system has a septic tank and soU absorption system(SAS) and the SAS Is within 100 foot of a surface water supper
tributary to a surface water supply.
The system has a septic tank and soU absorption system and the SAS Is within a Zone I of a public water supply wou.
The system has a septic tank and aoU absorption system and the SAS Is within 60 foot of a private water supply wou.
The system has a asptJc tank and aoll absorption ►ystom and the SAS Is loss than 100 foot but 60 loot or more trom a
private waist supply wall,unless a wall water anaJysls for collform bacteria and volatile organic compounds InGcstas tr,.
wsU Is free hom pollution from that facility and the presence of immonia nitrogen and rJusto n1vo7m Is rgwa1 to or Io s,
than 6 ppm. Method used to detsrmine distance _ (approxJmadon not valid).•
3) OTHER
I
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corrtinued)
PTopertyAd&—: 18 Agawam Road, Marstons Mills
Ownet: Lisa Wood
Date of inspection: 6/3/9 9
D. SYSTEM FAILS:
You must indicate either 'Yes' or 'No' to each of the following:
I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this
determination is Idendfied below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No _
y/ Backup o+"Wage iRtoiacilitywr vTstmn component dua¢o an overloaded orcbgged'SAS or•cesspod.
l! 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 e,dlstrlbutlon bo4 above o tlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth In*orrpvvH1 less than 6' below Invert or available volume Is less than 112 day flow.
Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).
,/ Number of times pumped �.
_ 'V Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation.
411 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•wlthin a Zone I of a public well.
k1 Any portion of a cesspool or privy Is within 60 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. If the well has been analyzed to be acceptable, anach copy of well water analysis for
coliform bacteria, volatile organir,compounds, ammonia nitrogen and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must Indicate either 'Yes' or 'No' to each of the following:
The following criteria apply to large systems In addition to the criteria above:
//- The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No ,
/�/� the system Is within 400 lest of a surface drinking water supply
lV the system•is-within 200 feet of a t«butery to a surlooadrk>♦ciwg wate+supplY •• ---
the system is located In a nitrogen senaltive 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 upgrade the system In accordance with 310 CMR 15.304(2)• Please consult the local regional
office of the Department for further Inforpadon.
revised 9/2/98 Page 4ofII
I
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 18 Agawam Road, Marstons Mills
°`Mf1e` Lisa Wood
Date of Inspection:6/3/9 9
Check if the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following:
Yes No /
Pumping information was provided by the owner, occupant, or Board of Health.
-None of tha systemcomposrnta.kauaj. aan puaVod4ovat,Jeast two we&"an&the'rystem ha4baaoaecaiQ64-g WASAW Aow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
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 system does not receive non-sanitary or Industrial waste flow.
_ The site was Inspected for signs of breakout.
_ All system components,�Wacluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffle:
77t"" 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. For example, Plan at B.O.H.
_ Determined In the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b))
v _ _ The facility ownar.(and.o•paa!C,If differaat irnat oaunar).►orate praxidad.wiih Iniouna.ioaon rh�r�nP��ainta� of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
NopertyAd&&": 18 Agawam Road, Marstons Mills
own": Lisa Wood
Date of Inspector: 6/3/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedro
Number of bedrooms(1�de��signnff: Number of bedrooms(actual):�
Total DESIGN
Number of current residents:
Garbage grinder(yes or no):_ �
Laundry(separate system) �es ortC1OJ If yes, sepax"alnspaction.required
Laundry system Inspected (yak or no)
Seasonal use(yes or no):
Water meter readings,If available (last two year's usage(gpd): �'/Gc!/� a4o�. / Al
Sump Pump(yes or no):� / —rl,d�a��r '(
Last date of occupancy:liGc3.._
COMMERCIALfINDUSTRIAL:
Type of establishment:
Design flow: d ( Based on 16.203)
Basis of design flow
Grease trap present:(yes or no)Zff
Industrial Waste Holding Tank present:(yes or noaLf
Non-sanitary waste discharged to the Title b s stem: (yes or no),&
Water meter readings,If available:
Last date of occupancy:_
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of Information:
System pumped as part of inspection:(yes or no)
If yes,volume pumped gallons 7�,
Reason for pumping: # E_ �' IQ&-;, k, � �',yIF
TYPE QF SYSTEM
I/ 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)
1/A Technology et Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Otter A2d
PROXIMATE AGE of all components, date InstWediif known)-and source of,iwformation: `
Sewage odors detected when arriving at the site:(yes or no)
revised 9/2/98 Page 6of11
i
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (corriinued)
PropertyAddra44:18 Agawam Road, Marstons Mills
owner: Lisa Wood
D— of Inspec8on: 6/3/9 9
BUILDING SEWER:
(Locate on site plan)
r/
Depth below grade:
Materla) of construction: _cast lion -1'40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter_L_ _ _..
Comments: (condition of Joints,venting, evidence of(aaksge,-etc.)
house vent .
S WC TANK:
(locate on site plan)
Depth below grader
Material of construction: Z concrate_metal—Fiberglass ,Polyethylene_other(explain)
If tank Is lneW,list age_ Is.age.conrtrmad by Certificate of Compliance_ (Yes/No)
� fir• ( �� 8/1
Dimensions:
Sludge depth: -'
Distance from top of sludge to bottom of outlet%as ortmtfle:
Scum thickness:_
Distance from top of scum to top of outlet tee t bto o �_
Distance from bottom of scum to bono of outlet to or baffle:
How dimenslons were determined: 00
Comments:
(recommendation for pumping, condition of inlet and outlet teen or•batfles, depth of liquid level In relation to outlet invert, svucturea;r,teprity
evidence of leakage,etc.) P U M 12 t q n k P y P r jr —
are in
GREASE TRAP:
(locate on site plan)
Depth below grade:��
Material of construction oncrete)f�tetal�Ibstglass.�,Polyethylene,�other(explain)
DimensionsAr=�
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of sc to bonom of outlet tee or batfle:.4,27
Date of last pumping:
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, etc.)
Grease
revised 9/2/98 Page 7orII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropenyAd&—: 18 Agawam Road, Marstons Mills
Owner: Lisa Wood
Data of Inspection: 6/3/9 9
TIGHT OR HOLDING TANK:(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of cons truction4&concreteo(wetalAFiberglassi&iPolyethylene.�other(explain)
VA
Dimensions: i)A
Capacity: gallons
Design flow: gallons/day
Alarm present n
Alarm level: Alarm In working order:Yeshl,4 NON
Date of previous pumping:
Comments:
(condition of Inlet tee, condition of alarm and float switches,etc.)
lignt or holdin2 tanks are not prPRPnt _
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet Inven: AlQ
Comments:
(note.if level and distribution Is equal, evidenoo of solids carryover, evidence of leakage Into or out of box, etc.) — —
Distribution box has one lstprnl Nn evidence of solids Carry
over . No Pv; dpnrp of leakage into Qrout of the he* .
PUMP CHAMBER:—A&j/e
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ftnip chamber is not present .
revised 9/2/98 Page 8of11
�I
SU8SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Prop-tyAd&—: 18 Agawam Road, Marstons Mills
O1Mf1 : Lisa Wood
Dau of Irupectiori: 6/3/9 9 �I
SOIL ABSORPTION SYSTEM(SAS): I
(locate on sit@ plan, If possible: excavation not required,location may be approximated by non intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:O
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimension
overflow cesspool, number-
Alternative system: 4
Name of Technology: & 7, �'i
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
tuaimy sand to medium tine sand . No signs of hydraii1 i r
ai ure or Pon ding . Vegetnt; nn ; Q nnrmal
CESSPOOLS: aoe-
(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: .4.159
Materials of construction: 4111
Indication of groundwater:
inflow (cesspool must be pumped as part of Inspection)
esspoo s are not present _
Comments:
(note condition of soil, signs of hydraulic failure,.level of ponding,condition of,vegetation, etc.)
Cesspools are not nrPspnt _
PRIVY:4Aje,
(locate on site plan) ''JJA
Materjals of constructi n:_ NT Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
r1Vy is not present _
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM L14SPECTI0N FORM
PART C
SYSTEM INFORMATION (coadnwwd)
PTc06MAda.L4: 18 Agawain Road, Marstons Mills
o""'" Lisa Wood
on, or��«,:6/3/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include dsa to at last two permanent ra(aranca landmarks or benchmark&
louts all walls wINn 100' (Louts what► public water supply comas Into house)
Centerville Osterville Marstons Mills
Water Company
428-6691
0
.�s •os
o
fra�T'
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropenyAd&—: 18 Agawam Road, Marstons Mills,
Owner: Lisa Wood
Date of Inspection: 6/3/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to GroundwaterItf Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plars on record
�served.Site (Abutting paopert observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_zchecked pumping records
Checked local excavators,.installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water Contours Map .
Used Gahrety & Miller Model
tali�lC�
revised 9/2/98 Page 11 of 11
_s la•Ir.;RT�111TI�TI"'\RII'AII'I.IIf/ITIwiJn#R1'71'TI/T1I.'Rll.n tlR\1/A�111�`f lfT .TT"rT'� .TeT•...�..p. ...'
'!'UNN OF �I�I2TARI P, BOARD OF HEALTH
SUIlSUftFACF, 9F.K�AUF U! 1'USAL SYF,M�3T IH9f'CTION FORM — PART D •— CEIZTI FICATION I
aTan RIIRTT.T\T1�TT't•r�..��T'A.1. —..A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS _ 18 Agawam Road, Marstons Mills '
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' S NAME Lisa Wood
PART D - CERTIFICATION f
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P. Macomber & Son', Inc .
COMPANY ADDRESSBox 66 . Centerville Ma . 02632-0066
Strout Town or City Stt
ClP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578
CERTIFICATION STATEMENT "
I certify that I have personally inspected the sewage disposal system at
this address and that tile information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recommendatlons 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
V System PASSED
Tile inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or tile. environment as defined. in 310 CMR 15 - 303 . Any faililre
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this forin ,
System FAILED*
The inspection wi►icil I have con'd"ttcted has found that the system fails to
protect the ilublic health and the environment in accordance with Title
5 , 310 CMR 15 - 303, and as specif-ically noted on PART C - FAILURE
CRITERIA of this inspection form .
Ins ecto
p r Signature ( Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF )iBALI'll;
• If the inspection FAILED, the owner or."hoporator shall u
within one year o(' the date of the inspection, unless alloweddortrequiredm
otherwise as provided in 3.10 CMR 16 . 306 .
partd . doc