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0018 CALICO LANE - Health
18 Calico Lane,Marstons Mills , a a TOWN OF BARNSTABLE LOCATION fill, C AI�G P� �Ai � SEWAGE c&c4esG�6ti VILILAGE C7S (i j � ASSESSOR'S MAP & LOT q INSTALLER'S NAME&PHONE NO. "( r g UM re�L9 S ' f SEPTIC TANK CAPACITY /T dam ` ' LEACHING FACILITY: (type) eQ_ kirk ZQ706 (size) 6 1�'� NO.OF BEDROOMS BUILDER OR OWNER PEFMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I r I^ Ccx.1 i C o l_.ar),e— C�>S 1 inv I vvx ol 1 IAIIOE L V0 o�� LOCATION SEWAGE PERMIT NO. Ofelcin VILLAGE �OINST LLER'S NAME & ADDRESS i � e UILDE R OR OWNER R� (h A Q s�T, Fs C DATE PERMIT ISSUED / DAT E COMPLIANCE ISSUED � � ._ � 41-� v`5�� rl a Gr 1 1 -77 B ki- F ........... SS 41 THE COMMONWEALTH OF MASSACHUSETTS BOARD F I-iEA ............ _. ............. .OF........ ........IC Y--� Apli iratiun -for.Diipuutt1 Works (nunfitrurtiun Vrrniit Application is hereby made for a Per it to Construct ( or Repair ( ) an Individual Sewage Disposal System a / � 11 .......-.. ..............1.`' f✓'1C .lam---l�.F = /C� -------- ----- Lo Address ��j^� o o, W Owne / Address ---....-- •.. --- 1------------------ ` - ---- ------- ---- /... Installe Address UType of Building Size Lot.......... .. .......Sq. feet Dwelling—No. of Bedrooms.......... .................................Expansion Attic ( ) Garbage Grinder 0er4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.�0-_gallons Length---------------- Width................ Diameter.......--------- Deptll....------..-.--. x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........1".1 Diameter-------------------- Depth below inlet.................... Total leaching area..--------....__--sq. ft. Z Other Distribution box ( ) IDosing tank ( ) Percolation Test Results Performed by-------- ----------------------------------------------------------------- Date........................................ a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-------..-.............. (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-----------------. P4 -------------------- -------------------------------------------------------------------------------------------------------------------------------------- ODescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ W U Nature of Repairs or Alterations—Answer when applicable................................................................................ ............... ---------------------------------------------- -------------------------------------------------------------------------------------------------.....------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the ov'sions of Article XI of the State Sanitary Code—The undersigned further agree not to place the system in o t' n until a Certifica of Compliance has been issued6bDythnbo d f healSigned . .. - � � Pkc ^at ation Approve B_ J): ._ Date Application Disappr ved f or t following reasons: -----------------------------------------------------------------------------•---._.....--._...............----.._....-----------............-------------•-•-----------------------------------------__. Date Permit No..... ............................... Issued....L- -l---95 Date �__. _ ----- -- .. ` Itlo........ .....�.. FicE....6.......................... .L ! _ :55 THE COMMONWEALTH OF MASSACHUSETTS IMF p BOARD OF HEALTH OF J� Applirttti;nn nr 40tipitittl Works TowstrurtioYt rr��it Application is hereby made for a Permit to Construct (Z.-)"or Repair ( ) an Individual Sewage Disposal System at / - ---11--- -=•-=�, c......--(....`-,-..._.='...``. ..... _.!�/--- ---------------------------- .... Location-Address y.� 7 / �f or'Lot`'No. / / ` l'�' /- ,rr'✓ '�T .d I `) ..l �j I I/ rX olli 1_174w-- dre••---•---•-••-•---- � Owner j `� / Address• w ............ ..............................•. ••.. ---------- ......................... .............. i . Installer , Address UType of Building Size Lot.... =::_rf_._.Sq. feet Dwelling—No. of Bedrooms--------23-------------- Attic ( ) Garbage Grinder aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------ --------------------------------------------------------------- ------------------_--------- w Design Flow-------------------------------------.......gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity._,�..'%_A.gailons Length------_-----_ Width................ Diameter.__-. --..----_ Depth-.-.------.----- x Disposal Trench—No_____________________ Width-------------------- Total Length-------------------- Total leaching area-------------.------sq. ft. Seepage Pit No------------------- Diameter-------------------- Depth below inlet_-___________-______ Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------- -----------------------------------------------------•---•---••-- Date--------------------------------------- ,� Test Pit No. 1--------------..minutes per inch Depth of "Pest Pit.................... Depth to ground water-.................... ( Test'Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--._..--------_-_-_----. P4 --------------------------------------------------------••---•----•-•------•-----------•------•---•-......................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x U -------------------------------------------------•----•-•--••--------•-•-----•----•-----•-----•------•-•-••-•---•----•----.------------------------------------------------------------------------- w U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: ----------------------------------------------------------------------------------------------------------------=------------------------------------------------- ----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by,the board of health. Sign-,I '-.. ------......•----•----------------- ------------------------ a- te • Application Approved By------ ----------- ----- . --------------- --....±. ------------- a£ j ate Application Disapproved for following reasons: ---•---------------------•-•-------•--------•--------••-•------------ .............................. Date Permit No---- .......................� Issued. ` - �ta .. F t � Date THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH ..........................................O F..................................................................................... QLrrtifirate of TlImpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------- j _,� Installer at..... f o "' `( -..._.---------------------------------------------------------------------------------------- has been insta ed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated.------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ------------------------------------ Inspector-----------I- d THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH �• �.� ..........................................OF.................................................................................... No......................... FEE....... R-tupolial IV k,q nnnfitrurlion Vrrmit Permission is hereby granted----------------------- --------------- ----------------------------•----._...--------.._...-----•-••---••-••---•-•••----_... to Construct (/l) o Repair ( ' an Indivi al Sewage Disposal System at No--------------- -••--A-.q-•---•• c:_L-�4c?. •---.........._ Street as shown on the application for Disposal Works Construction Permit o._9+_'5T _ Dat ------- .............___ ....... 1- � -----------------------• ----- .....-B-- oar of Health DATE....... .-------._...------------------...----------• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS u _DES/G/V Z.4 7A N /7� ZZ SEPT/G T.4Ne= DXZcro G. .O. . . � .O/SPQS,�I L P/T-//•SE �-/DGI�6.4 L. •Z'.SYoN.�" y oar '�'°'"= _ 'o �c • �X ti E -To 7-Q G.. 4- I>E.s/G��S/P�.r�G,.Ea,�t7' / /.c/ s A OF Is SULLIVAN No. 29i3; �, y;:� RtCHARD _ . A BAXTEr v. Q No.2`04-3 TEST tiv�/ ••. G a /�v✓. G.4L. ✓E� N'a.t-• 9yr� ps.a sEPrrC ` T�In�sC e2lw • -s7,4s ' ,014n/ ro / LE,eri�y TNQTTyE, XCs'y'� 1,5�/aw.v �OJ�STE,t?A,//G1a�Gj/��"a-.''� HE,�Eav G�MPLY�S /,v/T.�/T,yE.S/��'!-✓itiE B.dXTF,2 E�t/f�E /NG. A�S/v�SETl�/aG` .2EQU/,eEk1ENrS off' 7,�/� ieEGi.STE,ec'I,C.4rvp.SU,e�Eyo,� ToWxl L oc.Qr�v W/7W11y/ GA/A.1V IXI-57-e- '�_ -�/tifE�Yr-.Sv"VE ",4iV,p T//E a��ZSQ!5/. USEp I I. ���..�, l j _. 1 . .... .. t . . � � t "• �/G/V 0.4 7`,4 N I -47 / "W. .O/Sf'QS.�IL �/T-✓sS.E" �-/4GYJ cS,Q L. •Z�..SroN.E', .max '� 5XZ;E W. �14/4j�/r"Lof�f�'' I»f/�/�itt2G•,�,�7' / '/N /,�/, 1 s A 2� cP�SN Of gf� GiG Lam' 9c PETS n SULLIVAN No. LS/.iJ G3+� "�vRICHARD A. f3AX7LR v... Q . Z•ZT L'SY45 � � ev nio ••. G,a� . BoX WZ'- `5�` ,o TFl ANsC e mac✓ � =srm,✓,� �.. 95�G 95�� ' WV .4A/O✓�ETl�/1G` .2E4U/eE�IL�NrS o� T.y� ,eEGiSr�ecIJ.G4�✓O,S!/.etiEyo2s TOW1,1 aF,e*464&70 l 5' ,dNl /.S NOT C�ST�.21i/LLc' �+ !�Al AIV/iY-S7 e- Ta E.ST.�l/L/.Sy Lar- G/N�'S cam, Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name - r information is Osterville Ma 02655 6-27-2019 •:' required for every Mil page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 w Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number i B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey o� � �.4.�•m„•�,��.�a� �.�.��s 6-27-19 Oele:2 .0 14:2439-0CW 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 0 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: a ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f c Commonwealth of Massachusetts Titleicia Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 18 Calico Lane v Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. System will pass unless Board of Health determines irr 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ID Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '4 18 Calico Lane ' V Property Address Joseph Guarnotta Owner Owners Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 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 '/day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ O The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 c Commonwealth of Massachusetts �d Title 5 Official Inspection Form lel Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane v� Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes' or"no"for each of the following for all inspections: Yes No ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ n Were any of the system components pumped out in the previous two weeks? 0 ❑ 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? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? 0 ❑ Were the p septic tank manholes uncovered, opened, and the interior of the tank P inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ O 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: ❑ El Existing information. For example, a plan at the Board of Health. o ❑ 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.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •mot: 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: no design plans 4 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes Q No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? 0 Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): See below Detail: 2018- 84,000gallons 2017- 106,000gallons Sump pump? ❑ Yes ❑Q No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c� Commonwealth of Massachusetts �e Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l; 18 Calico Lane v� Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane v� Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: R Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 3-1-1985 per COC date Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 30" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts �n 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane V� Property Address . Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection i D. System Information (cont.) 6. Septic Tank(locate on site plan): 1811 Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 1211 Sludge depth: 2411 Distance from top of sludge to bottom of outlet tee or baffle 4" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1311 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Ofticdal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA 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.): I 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.726/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts ra Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 18 Calico Lane tiV� Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm resent: Yes No P ❑ ❑ 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 9. Distribution Box(if present must be opened) (locate on site plan): Or' Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: El leaching pits number: (2) 6'x6' pit ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Both pits were 1/2 full when viewed. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r; 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i l5insp.doc-rev.7/26/2018 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately IL0VAT11o:N sEwAcF rIEIp!INIT x0. V 1 L:L A'G t t 1/ 5T LIaR'S 14 A WE Ab"E'SS. R U I L,R E R; OR DWKtR b A 1 E IM A wit' t 5 i ii► � � ��"_r��s" DAT.t C &MP-1lANCL IS5U1D c> -�- 9E 44 -3 .' " l5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r cam, Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane v°- Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ■❑ Surface water ■❑ Check cellar ■❑ Shallow wells Estimated depth to high ground water: NO GW 10' below SAS feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) 0 Accessed USGS database-explain: USGS TOPO maps You must describe how you established the high ground water elevation: USGS TOPO maps show property elevation to be greater than 30' above high ground water. Bottom of SAS is at 10' leaving a greater than 20' separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 l c Commonwealth of Massachusetts Title 5 Official Inspection Form °l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Calico Lane u— Property Address Joseph Guarnotta Owner Owner's Name information is Osterville Ma 02655 6-27-2019 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Q■ A. Inspector Information: Complete all fields in this section. �■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked �■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed f F■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental ProtectionVAMM F.Weld b Trudy Cox• Cr "ALB' s n..' y,Eon► SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DwW S.Struhs PART ACWNnbWWW t ,1,99 CERTIFICATION ' k � 6 cc Property Address: 18 Calico Lane, 9skw+H -MA Address of Owner: Date of Inspection: August 7, 1996 (If different) Name of Inspector: Gordon E. Bunpus Company Name,Address and Telephone Number: Ocean General Contracting, P.O. Bax 659, Osterville, MA 02655 (508) 428-5640 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails j l Inspector's Signature: r ��G�6 Date: August 19, 1996 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit . the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AJ SYSTEM PASSES: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltradon, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming tic tank as P g septic approved by the Board of Health. (revised 8/15/95) 1 Ons Winter Strsst • Boston,Massachusetts 02106 0 FAX(617)NO.1049 • TMsphons(617)204M a I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 Calico Lane, Osterville, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 B] SYSTEM CONDITIONALLY PASSES (continued) 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 distribution box is levelled or replaced The system required pumping more than four 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 Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE;PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. (revised 8/15195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 Calico Lane, Ostemlle, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 DJ SYSTEM FAILS (continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year N-Qa due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: 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 Welhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 18 Calico Lane, 0sterville, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 Check if the following have been done: V Pumping information was requested of the owner, occupant, and Board of Health. v 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. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. V 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, excluding 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 baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ✓ The facility owner (and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. (revised 8/15/95) 4 f Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 18 Calico Lane, Osten4lle, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: _3 Number of current residents: 2 Garbage grinder (yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use (yes or no): Ab Water meter readings, if available: 151719 Last date of occupancy: Present o�ied. COMMERCIALANDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present (yes or no): Industrial Waste Holding Tank present (yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Never quiWed (per owner), System pumped as part of inspection(yes or no): Yes If yes, volume pumped: 1500 gallons Reason for pumping: Maintenance 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) Other(explain) APPROXIMATE AGE of all components, date installed(if known) and source of information: 1985 Oer owner and Town gf Barn. Sewage Permit) Sewage odors detected when arriving at the site (yes or no): No (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 Calico Lane, Ostemille, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ concrete _metal _FRP _other (explain) Dimensions: 5'8"X 10'6" - 1500 lg�lon sg2tic tank Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 2'4" Scum thickness: I' Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 1'2" 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.) Baffles are in good LhWe. Liquid level is even with outlet invert. 11b leakage observed. Recommended guiWing eve t� hree years. GREASE TRAP: Mne (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _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: 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.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 Calico Lane, Osterville, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 TIGHT OR HOLDING TANK: Alone (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Bar is a"below grade and is level. No evidence¢' leakage or solids ca=ver. PUMP CHAMBER: 11bne_ (locate on site plan) Pumps in working order(yes or no): Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 Calico Lane, Osterville, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 SOIL ABSORPTION SYSTEM (SAS): ✓ (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, number: 2 - 6'X 6'Aits with stone leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Soil was drv. Ab sign �f nonding. 11b sign¢' JWMulic failure. vegetation was normal CESSPOOLS: None (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: None (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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 Calico Lane, 0sten4le, MA Owner: Richard R. Stimets Date of Inspection: August 7, 1996 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100'. OA�c� of ttovse a F ARE ° A E c O OD G O AC - 12' BC - 53' AD -21' BD -45' AE -41' BE -34' AF -77' BF - 24' AG -64' BG - 39' DEPTH TO GROUNDWATER: Depth to'groundwater: 40' feetfom bottom ¢pit to water. Method of determination or approximation: Qe Cod (nn3,miscion Water Table,Contours MW and U.S. Geological Taoogran 'c Man. (revised 8/15/95) 9 POL y DATE 5/13/05 PROPERTY ADDRESS 18 Ca.eico Lane . E'll ® 1 17a.3,3 026 5 5 On the above date, the.iieptic system at the address above was . Inspected. This system consists of the following:. , 1.1 1-1500 gaiion 3ept.ic tank 2., 1- Di-At titut.ion Box-` �:` .< c.- 3,• 2- 1000 gaijon ieach.ing. /?its. - -- Q Based on inspection, I certify the following conditions: 4. 7hih 1,3 a 71tie T.ive Septic Syztem (78 Code) w � 5., The .6ept.ic 6ybtem 1,3 •in p/tope wo2kcng o2dea at the w � /�2ebent t.ime.� SIGNATURE - Name: Robert A. Paollni Company: Joseah P. Macomber &Son Inc . Address: P. O. Box 69 Centerville, Mass 02632 Phone: 508 775.3338 or 508-775-, •JQSEpH P. MACOMBER & SON;.INCG" ' Tanks.Cesspools-LeachfleWs Pumped &••.InsWI8d Town Sewer-Conneefions P.O. Box 66 . Centerville, MA 02632-0066 . 775-;SP. $ . 7.75.6412- COMMONWEALTH OF aNSSACHUSE'I"TS EXECUTI OFp'I0R OF_flNV GrNM'EN'TAL AFFAIRS �. DEPAR.TA�iENT•OF�NVI�O�� �A3�P1Z�T'�CTION TITLE.5 . OFFICIAL INSPECTIOPI'TO�RM TT FO VDLVNT"y ASSESSMENTS SUES ACE SEWAGE SYSTEM FORM SE PART•A CERTIFICTION property Address: • 18 C a_t�c o L a a e . owner's Name: N a n c N L6 e 11,6 owner's Address: a e Inspection, 5/13/0 5 , Date of Insp • '� —• inty2 o.�ea t i a o 4 n.i co w i Name of Inspector:(please pr� � Ala_ o�m$.Q�t- 8�n Lac. x •'-v . �� . ' Company Name•N dO �n Mailing•AW .. ab,�.•02¢32. . ... Telephone Numb er: 5 0.8-•77 j m CERTIFICATION ST AILMENT . rnaed based on my inspected the sewage disposal system at this address andetrfo•information repotted I certify that I have personally tnsp ection,The inspection was p below is true;accurate and complete as of the time of the Insp rem. approved system inspector pursuant t"6 training and exp r finietion and maintenance of on31 sewage o)�The I am a DEF erience in-the proped'on.13:340 of• le 5 XXX Passes .__.— Conditionally Passes roving�Authoriry Nee Further Evaluation by the Local App ai �..� r Dater , ._. Inspector's Sinatnre: card of Health or of this�spectinn 46rtto the•APpro�$Audwrity(B The system inspector shall submit a copy to .� gh*4 sy or has a design flow of 10,000 DEP)within 3o days of completipg this inspection.If the sys t crt to the appropriate Tegional•o�ee of the d or Beater,the vispector and the system owner.slialYsubmitrherep PF •ticabie,mdthe approving gp• �cs sentw the buyer,if app DEP.The origmal should be sent tom system avrnm a�a authority. Notes and Comments d ****'t'hls report only de scribes conditions at the time of inspection-and an t b conditions u under the same or different time.This inspection does not address how the system wUl perform in the conditions of use. Page 2 of 11 OFFICIAL INSPECTION:FORM—.NO:TT FOR VOLUNTARY. ASSESSl1 N'li'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. ' PART'A CERTIFICATION(continued) Property Address: 18 C.¢Z v_n U-6 T-e It ZZ ze_ Owner: N¢n cu N i, Date of.Inspection: 5 Inspection S.un ma'ry: :Ch;gA A;,t3;-,D or.E'/A V omp�loWall of Section,D A. System Passes: Ye-3 NO 'I have not found any information whicli 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. CQ�pments: /he 6/2e.t-iC .5y.5.tem j13 in /120Re2 wo2k"ina 02de2 /f Lhiownnf B. System Condltionafy Passes: NO 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 Jetermined(Y,N,ND)in-the for the following statements.If"ndt determined"please explain. NO The septic tank is.metal:and.over20 years okl*or the'septic-tank(whether•metal.ornot)is:slruchural)y unsound,exhibits substantialeinfiltratiun or exfiltration.or'm*.failore-is minent:System will pass inspection•if3he existing tank is replaced with'a complying,septic •asroved 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: "A NO Observation of sewage backup or breakout 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 insP4ction.if(with approval of Board of Health): broken.pipe(;).are replaced. . obst ruddon is removed' ' distrib9fibb box,is leveled or•replaced ND explain: NO The system required pumping:-more than 4 times a year due to broken or obstructed pipe(s),The system will pass inspection if(with approval of the Board of Health): F broken pipes)are replaced obstruction is removed ND explain: Page 3 of 1 I p 'ICIAL UEC`I'ION FOR117i N©T01a�'fiILUN'�'AR� ASE�3NI�i�ITS g1�1RF ACE gFW.,�i�CL3ROStd;L syS�'E1Vi l<NSP'1�CTI�N:. RNi 5iJS PART.-A . . CTRTITI' CAIION.''(6orit!nped) : Property Address: 18 Cail CO .Late Owner:ll a a c b e Date of Inspection: of Healtb: aired by the Board C. Further Evaluation is Req i en.. . NO s.existwhich.reyuirefurtl�er•.earaluationbY•theB°aTd'o�HeBlth=�'or:9er.�to;deterniineifthesyst Cond:tton or the environment' is failing to protect public health,safety that,the rotect public health,safety and•tbe:•enYiropmeat: System will bass unless Board-o#Health determfnes4ii�aecorda ce with 310•CMl<t 15:303(1) 1 sy is-a mariner!which=will p system is.not fanctioning N U wit 50 feet of asurface water etated wetland or a salt marsh• Cesspool or privy'ris-NZT Cesspool or privy is within 50.feet of a bordering wag . - determines that the ' m will fail unless the Board of Health{and Publicbp ors Supplier;ty,and enviroa�►t: 2• Syste roteets thep0 system is functioning in a niatiner,that p NO stem has a septic tank and soil absorption system(SAS):and the SAS is within 100 feet ofa The ry to a surface water supply surface.water supply or••tributary stem has a•septic lank and SAS and the'SAS is within a Zone 1 of.a=public water�supply s NO The y N U has a septic tank and SAS andthe SAS is within:,50 feet of a private water.supplY _ The system and SAS and the'SAS is less than 100 feet.birt 50 feet ox more frol►a N U The system has a septic talc V u a._ private vale water supply well**.Method used to determine distance' the well water analysis,perfornmd at a DEEP certified laboratory,,for coliform **This system passes if m, vided that no other volatile organic corinpounds indicates that the equal to or Bess than 5.ppon pro nl that facility t bacteria and en is the presence of ammonia nitrogen and f nithe rate b atsached tot*form, failure•criteria are mggered.'A copy 3• Other: Page 4 of 11 OFFIC AL-INSPECT ON FORM NOT TOR VOLUNTARY ASSESSMENTS -SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSP.ECTION:FORM PART A CERTIFICATI0 1(continu od) Property Ad dress: 18 Ca eico Late b e2,L e OwnerNanc r(G�3QQG4 Date of Inspection: 5/1 0 5 D. System Failure Criteria applicable to all systems:. You must indicate."yes"or"no"to.each.of the 1ollowing,for all inspections: Yes No X Backup of sewitgo:into•fa*ty::or system component.due-to,overloaded.or clogged SAS..or.cesspool X Discharge.or ponding of effluent to the.surface of the:.gound or..surface:waters due to.an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or —' cesspool X Liquid depth in-cesspool is less thank"below invert or.available volume is less dm%day flow .X Required pumping more•tham4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of. SAS,cesspool or privy is below high ground water elevation. _ X Atiy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion.:of a cesspool ror.privy is within a:Zone:1.of a.-public.well.. X Any portion of a cesspool or privy is within.50 feet of a private water supply well. X Any portion of acesspool or-privy is less than 100 feet but greater..than 50 feet from a.privam water supply well with no acceptable water quality analysis..[This.system.passei if the well water:analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organkeompounds indicates:that the well is.free from pollutionjromAbot,facility and:thg 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 attache&to this form.] NO -(Yes/No)The system fails.I have determined that-one or.more,ofthe:above.failure.•criteria exist as described in 310 CMR 15.303,therefore the.systenj 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 systetnthe:system must.serve.s-:facility,with a design flowof 101000 gpd-to 15,Q00. You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the-system is within 400 feet of a surface drinking-water supply X the system.is within 200 feet of a tributary.to a surface drinking water supply X. the:system is located in a nitrogen sensitive area interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner-or operator of any large system considered a significant threat under Section E or failed tender 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �— SttBSURFACE SEWAGE DISPOSAL'SYSTTM INSPECTION FORM PART B CHECKLIST Property Address: 18 Catico Lane Ub�e2U.G•�.ee . Ownerivancu fltzeii,,6 . Date of Inspection: Check if the following have been done.You must indicate` f or"no"alto each.of the foilowin Yes No _ . _ X Pumpir..g information was provided'by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as-part of thisinspection? o. X Were as built plans of-be system-obtained and examined?(If they were not available-hote is N/A) X Was the facility.or-dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out X _ Were all system componentsjkicluding the SAS,located on site? X _ Were the septic tank manholes.uncovered,topened,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? X _ Was the facility owner(and occupants if diffbrent from owner)provided with information on the proper maintenance of subsurface sewage disposal systems.? The size and location of the Soil Absorption System(SAS)onthe site.has been determined based on: Yes no , X Existing information:For example,a plan at the Board of.Health: " _ X 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 11 OFFICIAL V4SPTC'FI0N::k'-}RM`—NOT FOR V.OL.INTARY ASSESSMENTS � .SIlRSMACE SAGE D1W0SAL+SYST 4'M ENSPEET10N FORM PART.0 SYSTEM.WORMATION h Property Address:18 Ca—U c o Lane Owner:Nancy 17.77e lA Date of Inspection:„ 5/13 0 5 FLOW CONDITIONS RESIDENTIAL Number of bedroAms(desjign):• 4 Number ofbedrooms{actual): 4 DESIVflow based on.3la C1V'ilI 15.2.05'�(for exaiuple:'l Mod z#dbedrooms): X T-/0=4 4 0G%D Number of current residents: Voes-residence have a garbage grinder(yes br no):yes Is laundry on a separate sewage.system.(yes or.no):.no [if yes separate inspection required] Laundry system inspected(yes or no)n o , Seasonal use?(yes orno):_a0 2003=881 000 gae2ons rjP -241. 09 Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 4=9 8 0 0 2 2 o n s G�[7=2 6 8 49 Sump pump(Yes or no):n°O Last date of occupancy: R 2 e e n t I COMMERCI'LP- bUSTRIALNA . Type of estatl t: Design flaw. on 310 CMR 15.203).:• and Basis.of d i ow(seats/.persons/sq%etc.)., Grease trap present(yes.or no): Industrial waste holding tank present.(yes or no):_ Non-sanitary waste discharged to the Title 5 system•(yes or no): Water..meter readings,if available: Last date of occupancy/use: . OTWR(describe):. Y : GENERA•L INFQATION ' Pumping Records N,4 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 X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool ._Privy _Shared system(yes or no)(if yes,attach previous inspection records,if 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): Approximate age of aU components,date installed(if known)and source of information: unknown Were sewage odors detected when arriving at the site(yes or no):n o 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 18 Ca.e i.c.o Lane O.s.t eay.i.9ie Owner:Na n c y rl.t z e .t s Date of Inspection: 57 7 77 5 BUILDING SEWER(locate on site plan) Depth below grade: 3' Materials of construction:—cast iron X 40 PVC_o e�(+ lanP: Distance from private water supply well or suction line: e e Comments(on condition of joints,venting,evidence of leakage,a ): joirttz reae tight Zystem vented 4haoug house vent. SEPTIC TANK:y e h(locate on site plan) 15 0 0 g a.R e o n Depth below grade: 12 Material of construction:R concrete metal,_fiberglass_polyethylene _other(explain) If tank is•metal list age:_ Is age confirmed by a Certificate of Compliance(yes:or no):_(attach a copy of certificate) Dimensions: 10' 6"LX5 ' 8"KX5 ' 8"1d Sludge depth: t a a c e Distance from top of sludge to bottom of outlet tee or baffie:t a a c e Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: t a a c e Distance from bottom of scum to Bottom of outlet tee or baffle. a a c e How we're dimensions determined; m e a e u 2 e d ' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pi mp tank eveay yeaa. Gaagage d.i,31?oza.e .iz 121tezent., Zneet outset tee4 aae in /e,euc.e. i an t j 3 uctajtaff�f —S�DZL7CLL- GREASE TRAPn O(locate on site plan) Depth below grade. ' 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: 0. A— Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): aaeahe taaI2 .i.6 not p1te-zent Title t II...+..L/1 CMAAA 7 Page 8 of I I OPPICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS k'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:18 Ca44eo -lino Owner.Nancy zeiiz Date of liispectlon; TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspettion)(locate on site plan) Depth below.grade: Material of construction: concrete metal fiberglass___polyethylene other(explain): Dimensions: Capacity: —gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm'in working.order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 7.LGh.t oa hn.Pding fnnkA nno ani�nnolygnf,, DISTRIBUTION BOX:.- - (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.): Box* .i-s —Pe ve-0 ox lz , 'No .60 ei L eaa2 ove2., No 2eaka e .crz 02 ou o ox.; ' PUMP CHAMBER:NO (Locate on sife.plan) Pumps in working order(yes or.no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,ett;.): l umI2 cham&ea is no.t< P2eaent:- 87 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 18 Ca Pico Lane O�te2v.i.P.Pe Owner:. Nancu Nine eiz Date of Inspection: 5/13/0 5 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required) If SAS not located-explain why: Located see /2a.gp, �O Type X leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ;�. Loamy to medium sand.! No gn.6 o� $n;L6 n4eLY4,9646gz on tz no2ma . CESSPOOLS:NO (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: ^ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce s sl2oo iz ate not /2/tedent., PRIVY: NO (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): l 2.Lyy Gb not—f22Pi5 n 1 - 9 . Page 10 of 11 _ GiA Y1vSPF,�7,TOiv.I+iOR�Vi�NOT Fold'Y•OLUNT-ARY-ASSESSMENTS O . StBSLSAC-E''S',WAGEMlgP.bSAL SYSTEMINSPECT3ONTOR1V'f PART C . SYSTEM WMRAATI.ON(,c©ntitiued)' Property Address:l8 - owner: Date of Inspection: 5/9 3/0 " TCA OF SEYYAG�•DISPOSAL SYSTEM ovide a sketch of the sewage disposal system including ties to at least tw p =�the bu.'Ic I ���or Pr benchmarks.*Locate all wells within 100 feet.Locate where pubsupply, c0 C 0 L.. o C N � W 10 - Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS SS S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART C SYSTEM INFORMATION(continued) Property Address:l8 C a.t i c o a n e O�ste2v.�.2Qe Owner:Nance (7 ire ins Date of Inspection: 5/13l 0 5 SITE EXAM Slope Surface water Check cellar Shallow wells. Estimated depth to ground water 5 0 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: hole within 150 feet of SAS) u e�Observed Site(abutting property/observation. - . Checked with local-Board of Health-explain: 9., : 0 l n n n,! no Checked7with local excavators,installers-(attach documentation) 1�e 3AccessedUSGS database-explainhtt/2 t own.,&a2n�ta&fie. ma. ups You must describe how you established the high ground water elevation: �\ 11,3ed : Ca e Cod Comm j,3 on. 1dat e2 7ag 2e Coritou2h And I ug 2i e JJatea Sup/s2y kleii head aotect.io-n ..a2eaz ma Se t 1995 Vatea nehouace commizion., Leaching Pit 10 -eet L7V-] 40 Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is 4.,8 feet: 3 5. 20. 11 M"^""""'"''-""r '""" .�,� I30ARU OF IiEALTII TOWN OF ,134 1?N c741 F.- SUBSURFACF SEWAGE DISPOSA[, SYSTEM INSPECTION FORM - PART D•- CERTIFICATION,,_] .—xnT•.zvt+-.nnnat-'e'e+ra*+mr.s�'°�'°r' m^ v�,er,•-• -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED , STREET ADDRESS 18, Caeieo Lane ASSESSORS MAP, BLOCK AND PARCEL # 098-055 Nancy OWNER's NAME PART D CERTIFICATION NAME OF INSPECTOR Ro ge'At /oa.o1 in.i COMPANY NAME oseph :p.- Nacomle^ Son Inc COMPANY ADDRESS Box 66 02632 Streit Town or City. - 8tata EIP COMPANY TELEPHONE ( 508 ) � 7.5 - 3338 FAX ( 508 h90 1578 CERTIFICATION STATEMENT I certify that. I have personally .inspected ..the sewage disposi system at this address and that t}i.e information reported is true,. accurate., and omplete as of the time o.f ,•insp.ection.. The inspection was performed and any hecommendAtions regarding upgrade, maintenance , and irepair .are consistent with my trainii,,g and experience in the proper function and maintenance of on- site sewage disposal systems - Check one: XXXX System PASSED The inspection which I have .'conducted has ,n'ot found any information which indicates that the system fails to adequa''tely protect .public health or the environment as defined in 310 CMR. 15.303. Any failure criter.ia , liot evaluated are as stated in the FAILURE CRITERIA section of this form. . System FAILEU* \\-. The inspection which I have con acted 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 i s ion orm. Inspector Signature Date ne copy of this certifi.catioh must -be provided :to , the .QWNER, the. BUYER where applicable) and thO BOARD OF HEALTH. .. * If the inspection FAILED, tht owner or operator eha11 upgr.ade ' the system. within o'ne year of the date of the inspection, unless.. allowed or' requ.iyed otherwise as provided in 3.,10 CMR 16 , 305 . .. pa>•.td..doc- ......... ....... 41 t ol'i il y Az , gig, 0 "US _1h h. OEM"" • u.fiw. 71 It i.v __0 T -All np, MT Ral RM RE, N �,N MR,MW Ogg s-R, my a,W_n ORR R Sir L?03 15 NO .".xg�,,-j IFF. MW LL 'iN AIR gi 1? 11 1 2 St� 1 Amu "INS, �zk i,_=WW AMJ 5wl, s . . * gs, iRq � . . .. . g' , MI " O W 'Q ", U • MOM Wan An TUM " M NVA OTT DYE, 01— W 1- 14 "MYS MAN