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HomeMy WebLinkAbout0111 NOTTINGHAM DRIVE - Health CF:n`.- A-= -1 72-050 S M E A D No. 2-153LOR UPC 12534 smead.com • Made in USA ��crc�o �J cpa Ii I �sr_cO" MER USED IN TM PRODUCT LM I �SR PROGPM REQU�EFr�Nts sa�,Rc�,Ei°o �w�usawaoG+aunoxr: �-a - osa Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owners Name information is required for every Centerville Ma 02632 2/6/2021 page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. Inspector Information ' 51* I S I(Qz- filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Lane � Companypany Address Centerville - Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonesbtle5@gmail.com, SI4522 sean@smjonestitle5.com License Number 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 1 have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2/6/2021 Inspectors 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.7rM2018 Title 5 Official Inspection Form:S Wsuriace Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every page. CitylTown 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: ® 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 property located at 111 Nottingham Dr Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 500 gallon precast leach chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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): 15insp.doc•rev.7/26/201 B Title 5 Offccial Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every State Zip Code Date of Inspection page. Citylrown 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 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: t5insp.doc•rev.M02018 Me 5 Official inspection Form:Subsurface Sewage Disposal System•Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owners Name information is required for every Centerville Ma 02632 2/6/2021 page. City/rowwn 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 ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/260018 Title 5 Official Inspection Form:Subsurface sewage Disposal system•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every C Centerville state Zip Code Date of Inspection page. C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. El ® 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 11 of a public water supply well tSlnsp.doc•rev.7/26/2018 Title 6 Official inspection Form:SubsLrrrace Sewage Disposal system•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every City/Town state Zip Code Date of Inspection page. 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 ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® El available as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation 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)] Title 5 ofridal inspection Form:Subsirfeoe Sewage Disposal System•Page 8 or 18 t5msp.doc•rev.7128PZ018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey. Owner Owner's Name information is Ma 02632 216/2021 required for every Centerville CitylTown State Zip Code Date of Inspection page. D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® 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? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date Title 5 Official Inspection Form:subsurface sewage Deposal System•Page 7 of 18 t5arsp-doe-rev.72611018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Ma 02632 2/6/2021 required for every Centerville page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL, 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:. gallons How was quantity pumped determined? Reason for pumping: t5msp.doc•rev.7126=18 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 111 Nottingham Drive Property Address Nolan Hickey Owner Owners Name information is Centerville Ma 02632 2/612021 required for every Centern state Zip Code Date of Inspection page. D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: system repaird 8/17/2015 tank original 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 3 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.Qoc•rev.M60018 Tale 5 Official Inspemon Forth:Subsurface sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every City/Town State Zip Code Date of Inspection page. D. System Information (coat.) 6. Septic Tank(locate on site plan): 2.5 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 1000 gallons Dimensions: 5„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' 2" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" Opened covers and took How were dimensions determined? measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet,tank was not leaking and was structurally sound. Title 5 official inspection Forth:Subsurface Sewage Dispose'System•Page 10 of 18 t5insp.doc•rev.7IY812018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hicke Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every City/town state Zip Code Date of Inspection page. D. System Information (cost:) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Title 5 official Inspection Form:Subsurfaoe Sewage Disposal System•Page 11 of 18 t5insp.doo•rev.7/2612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/612021 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): 0" 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.): Distribution box was video inspected and found level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 118 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hicke Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every CitylTown State Zip code Date of inspection page. 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.): *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: [� 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: Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 t5insp.doc•rev.712812018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey - Owner Owner's Name information is Centerville Ma 02632 2/6/2021 kiwi required for every state Zip Code Date of Inspection page City/Town. 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.): s.a.s.consists of 2 precast leaching chambers in a 25"x13'trench. Leaching facility was dry at time of inspection with no high stain lines. Access cover is on a riser. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc-rev.7/26/201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 114 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewrage Disposal System Form Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every state Zip Code Date of Inspection page. CitylTown D. System Information (coat.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Oinsp.doc•rev.MUM 8 Title 5 Official Inspection Form:Substuface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Ma 02632 2/6/2021 required for every Centerville 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 i Z2 At z? zs I tA; �y �3 �Y S� Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 1Snsp.doc-ref.712612018 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is required for every Centerville Ma 02632 2/6l2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 12'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date El If site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. tShsp.tloc•rev.7146W8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ;L7) Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Nottingham Drive Property Address Nolan Hickey Owner Owner's Name information is Centerville Ma 02632 2/6/2021 required for every State Zip Code Date of Inspection page. cityrrown E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® 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 ® D. System Information: For 8:TightlHolding 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 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 tSlnsp.doc•rev.7/26/2018 p TOWN OF BARNSTABLE ? LOCATION :g�'�� ,/� ?1�n„ �� SEWAGE., 5� 7 VILLAGE ASSESSOR'S MAP&PARCEL 17k a INSTALLER'S NAME&PHONE NO. �2t STv�.�US SEPTIC TANK CAPACITY �( ® LEACHING FACILITY: (type) C o*_�D&j �` �„ size) ZS X13 NO.OF BEDROOMS OWNER �\%\ n PERMIT DATE: $'-{ v t'�5' 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 leaching facility) Feet FURNISHED BY Y � - � . � � � ; e k. � } t A� .Z� �� �'�� � I (U�,���,Hr►„ 630�3� r2 AZ =2 �z '`2S� �� � ��r / �� ��_ ' ��� : �� . . _U � � �9 : s� ,� �� �� ;; S �� r �' �;� '2G7�_ 1 No. ®� ` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Misposal 6petem Construction permit Application for a Permit to Construct( ) Repair(d-Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ►'li A w fn-,"V UI h„ 1 — Owner's Name,Address,and Tel.No. i �,�,,,, ®Sv titl lUok v�l d�rJ.¢. Gewliv�;l� ��,tst. Assessor's Map/Parcel rA�'Xj e—WA. Lp+ /® Installer's Name,Address,and Tel.No. l u S+")J-s Designer's Name,Address,and Tel.No. Y1Gy M fx 11 lh r rs s 7 it IS FKW. P6. Qox In m►",44d1 tsS. l Type of Building: Dwelling No.of Bedrooms Lot Size — sq.ft. Garbage Grinder( ) Other Type of Building Rtn No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33o gpd Design flow provided oZ, gpd Plan Date Number of sheets ° Revision Date Title Size of Septic Tank Type of S.A.S. bdpYS Description of Soil _ Nature of Repairs or Alterations(Answer when applicable) it Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar Signed Date Application Approved by Date — t Application Disapproved by Date for the following reasons 77 Permit No. ® Date Issued T 4 No. Fee THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS ` 2pplication for Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No.eh, L�f ee�hG r Assessor's Map/Parcel(�e V\)�-Y`hk)Z. 4'�A ®5v -D dh►�sS, Installer's Name,Address,and Tel.No. F ek� Designer's Name,Address,and Tel.No. rhrcSlo„ s h,115 MW. PG. 6,y. 0- s "d"c(" Type of Building: - Dwelling No.of Bedrooms Lot Size ,. _ sq.ft. Garbage Grinder( ) Other Type of Building ,-PC No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ' � gpd Design flow provided gpd Plan Date Number of sheets ;1 Revision Date Title Size of Septic Tank lo-1) Type of S.A.S. Description of Soil la 1 r. 1, Nature of Repairs or Alterations(Answer when applicable) �,���� E�64 �� 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boardof Health;\ Signed �� l // All VnDate 51 t,1/_,.r Application Approved by C c'""� /t Date -/ , —/ 5 u Application Disapproved by Date for the following reasons. Permit No. (� ! Date Issued I --------------------------------------------------------------------------------------------------------------------------------------- TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by /= r at i l A )f,1J e has been constructed in acccorda ce ,.a y,,,,a , .. ..�-sue• 2�� V J with the provisions of Title 5 and the for Disposal System Construction Permit No. 4 b fj_ dated V Installer F 1 , c ti"�,a��, q Designer 7�r #bedrooms "�.� 1ti Approved design flow gpd The issuance of this permit shall not be construed as la guarantee that the system will funct!nlas designed. Date" / j% � ,�,✓ x � l f 1 Ins- ------------- Ll ---------------- - -------------------------- ---------------------- ------- ----- ------- � +I- ---- No. (9G1S —�2(0 :�— Fee I THE COMMONWEALTH OF.MASSACHUSETTS !!l PUBLIC HEALTH DIVISION-BARNS TABLE,MASSACHUSETTS Disposal 6pstem Cons truction"Pefmit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at Ie 1 �,b-41-1 ;ho,,,, h- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. /-' Date Q r Approved by L Q, v Town of Barnstable ,�t►�rO , Regulatory Services o� Richard V. Scali, Interim Director anxtvsrnecE. 163 . ,�� Public Health Division tFe niw'�" Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: �? 1"J �� Sewage Permit# ?611-- ) 7- Assessor's Map\Parcel _146P. Designer: IV l Installer: WRAC_STEM ;= Address: Address: 02> -33 On 6VAC, ST Z was issued a permit to install a ( at ) (installer) septic system at based on a design drawn by (address) 4 Yens 1-1 G• dated (designer b"itAm".1— I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tfank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constru liance with the terms the RA approval letters (if applicable) Zak OF DARREN M M.- s Signature) No 140 (A kA . ...... `&Ni r �r� (Design Sign re) (Affix tamp Here) s PLEASE RETURN TO BARN ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- A ;' BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc i . I P# Town of BArnsta�ble �`f�"� � Department of Regtilatory Services i Public Health Division Bate_ • 6 9 06 e$ 200 Main Street,Hyannis MA 02601 i gqb Date Scheduled o �' Time ( � M Fee Pd. k- `oil Suitability AssessM1 *et�t,for Sewage Dispogal Performed By: �t,.—)1 5� Witnessed By: !/r� i LOCATION & GENERAL INFORMATION Location Address Owner's Name + PI Address J ��,A,"AA�� Assessor's Map/P4rcel: ���}^ � I Engineer's Name Vvt NEW CONSIRU�i;ON REPAIR x Telephone# 3 l Land Use Kf% � ��V Slopes(%') !30'/a Surface Stones Distances from: Open Water Body >'20b ft Possible Wee Are ��/'� ft Drinking Water Well �2 8b f[ i Drainage Way �� ft. Property Line ft Other ft SKETCH:(Street name,dimensiods of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) I � I i I i t 1 I r �y cc i Parcnt material(gecilogic (,l A, v���/tl,J� Depth t0 Bedrock Depth to Groundwatdr. Standing Water in Hole: i. r I Weeping from Pit Face Estimated Seasonal Vigh Groundwater DINE ATION FOR SEASONAL HIGHWATER T"LE Method Used: I I 1n. Depth observe standing in obs.hole: in. Depth td Sall t OU19s; Depth tolweeping from side of obs.hole: i in. Oroundwater Adjustment it. Index Well# Reading Date Index Well level ! - _ Adj.factor Adj.flroundwaterLevel,,,e I PIC tCOLATION TEST . Date Observation Time at 9" JAk Hole# Time at 61' ...——.� Depth of Pere Time(9"-6") Start Pre-soak Time.@ -- End Pre-soak . i Rate MinJlnch ! Site Suitability Assessment: Site Passed Site Failed: .___—_— Additional Testing Needed(Y/N) Original:.Public He$lth Division Observation Hole Data To Be Completed on Back---- i -you must first notify the ***If percola�ibn test is to be conducted within 100' of wetland,,y Barnstable C40servation Division at least one (I)weak prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,9'o Gravel V��2J l+ N ,all, � el 5AAA 3 j (OAt- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.°lo Gra el �0JL_ all�+ 1, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil 6ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravcl DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consisten ra 1 .t Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No / Yes Within 100 year flood boundary No, Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? _ If not,what is the depth of naturally occurring p rvious material? Certification I certify that on A-'/ (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the require r ' 'ng,expertise and experience described in 310 CMR 15.017. Signature Date Q:\SEPTIC\PERCFORM.DOC Town of Barnstable Barnstable Regulatory Services Department, ST� .039.A Public Health Division i6 �� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 3902 April 30, 2015 Phillip O. Brennan 111 Nottingham Drive Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 111 Nottingham Drive, Centerville, MA was last inspected • on 4/20/2015,by Patrick T. Sullivan, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit with high liquid level, <12" below pit (per Town Code 360-9.1) You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B ARD OF HEALTH cKean, R.S., CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future EAU 11 Nottingham Dr Cent Apr 2015.doc I _ Parcel Detail x T a r .. issgl2,'iritranetjpri p(lat1i,�,arre!Detail a,p i'!ID=117 7 1. Apps 0j http•-www,town,barn..: F Application Center a Suggested Sites rl Imported From IE EParcelLookup [ New Tab E' 0 Bing I ; Video,5 Incredible Tin.. a 14 977 81 MTARL�,� NAar, /try S t f y u �i .�} ii Parcel Info " Parcel ID 172.050 � Developer lot LOT 104 Location 111 NOTTINGHAM DRIVIJ Pri Frontage 100 Sec Road Sec Frontage Village CENTERVILLE Fire District C-0-MM Town sewer exists at this address No Road Index 1104�J Asbuilt Septic Scan, J.� � Interactive Map <�. 172050 1 1 5 • Ourner owner';BRENNAN,PHILLIP 0 owner Streett 111 NOTTINGHAM DRIVES Street2 city*CENTERVILLE State MA zip 02632 country Land Info _ Acres 0.34 use Single Fam MDL-01 zoning RC Nghbd 0105 Topography Above Street Road Paved utilities Public Water,Gas,Septic Location •�Cii0ruction Info t Year 1986 Roof.Gable/Hi Ext Wood Shin le Built struct p wall g � e 5 �5tart �14 Parcel Detail Google Ch,,, � J 0:5�are= �M Computer name : HEALTH899JF User name : flvnni Operatinq Svstem : Windows NIT (5.1) ,Town of Barnstable BAJWSTABM ,�� " Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/7/15 DEADLINES TO REPAIR FAILED SYSTEMS . (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA a Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or ' clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well o Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) Leaching pit with high liquid level, <12" below pit (per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc • �� Commonwealth of Massachusetts COPY Title 5 Official Ins ection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .._ 111 Nottingham Drive �;5°• �_. --------------------- ------------------..--------------Property --------------- Address Philli Qrennan Owner Owner's Name - — --- ---- --- ---- — information is required for every Centerville — — _ MA _02632__ April 20, 2015_ 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. General Information on the computer, use only the tab 1. Inspector: f/ key to move your cursor-do not Patrick T. Sullivan _ use the return Name of Inspector --- key. Ready Rooter Excavating— Q Company Name --— P.O. Box 89 Company Address Forestdale MA _ _ 02644 _ City/Town State Zip Code 508-888-6055 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority April 20, 2015 Inspector's Signature �' Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner ` and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. / \J41'-67 t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form != Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ( 111 Nottin ham Drive Property Address PhillipB rennan_ Owner Owner's Name information is Centerville MA 02632 A rll , required for every —._._...-------------— ---------- ----------- —p--20 2015 — - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced-.with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑' ND (Explain below): l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts _( Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Nottingham Drive Property Address Phillip Brennan Owner -- ----------._------- Owner's Name information is Centerville MA 02632_ A rll 20, 2015 required for every _� — page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break ou r high static water level in the distribution box due to broken or obstructed pipe(s) or due to roken, settled or uneven distribution box. System will pass inspection if(with approval of Bo d of Health): ❑ broken pipe(s) are replac d ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remov d ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of e Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): Elobstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is R quired by the Board of Health: ❑ Conditions exist which equire further evaluation by the Board of Health in order to determine if the system is failing protect public health, safety or the environment. 1. System will p s unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) tha the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address Phillip Brennan _ Owner Owner's Name information is Centerville MA 02632 Aril 20, 2015 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption sy tem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a sue water supply. ❑ The system has a septic tank and SAS and the AS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS an he SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and he 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 nalysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that o other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1= _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottnqham Drive _ Property Address -- Phillip Brennan Owner Owner's Name information is Centerville MA 02632 20, 2015 required for every _ _ _April page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 of et of a surface drinkingwater I supply Y ❑ Elthe system is within 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is loca d in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or mapped Zone II of a public water supply well If you have answered "yes" to any q estion in Section E the system is considered a significant threat, or answered "yes" in Section D ab e the large system has failed. The owner or operator of any large system considered a significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 31 MMR 15.304. The system owner should contact the appropriate regional office of the Depar ent. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.W 111 Nottingham Drive_ Property Address — Phillip Brennan Owner Owner's Name information is Centerville MA 02632 Aril 20, 2015 required for every __� page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 ------- Number of bedrooms (actual): 3---- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 489 GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - w Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive _ Property Address Phillip Brennan Owner Owner's Name information is Centerville MA_ 02632 April 20, 2015 required for every — --- ------------------ -- --- --p ---------- page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3-------- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013= 229 GPD g ( y g (gp ))' 2014= 276 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current — Date Commercial/Industrial Flow Conditions: Type of Establishment: - - ---- - Design flow (based on 310 CMR 15. 3): Gallons per day(gpd) Basis of design flow(seats/perso /sq.ft., etc.): - ------- - - Grease trap present? ❑ Yes ❑ No Industrial waste holding to present? El Yes ❑ No Non-sanitary waste dis arged to the Title 5 system? ❑ Yes ❑ No Water meter reading , if available: -- -- --- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 111 Nottingham Drive Property Address ---- ---------------------- --------- Phillip Brennan___ Owner Owner's Name information is Centerville MA_ 02632 Aril 20, 2015 required for every __ P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owners_records_Pumped March 2010 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: --- — --- gallons How was quantity pumped determined? ------------- --- ------- --- Reason for pumping: ------ ----- - — - —------- Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 111 Nottingham Drive Property Address ----------- -- ----------._._ --------- ----- Phillip Brennan Owner Owner's Name ---- - ----- information is required for every Centerville -_ MA 02632 April 20, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: _System July 1986_Certificate of Compliance on file at Health Dept. — _-- Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 4 — — feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): -- - Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 - -------------- - 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 8.6' X 4.5' X 5' 1000 gallons__ Dimensions: --------------- Sludge depth: 12" -- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address Phillip_Brennan Owner Owner's Name information is Centerville MA 02632 A M 20 2015 required for every _ _—____—_ _. _ —� page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) . Distance from top of sludge to bottom of outlet tee or baffle 20" — - Scum thickness 2±' at inlet Distance from top of scum to top of outlet tee or baffle 311-- - — Distance from bottom of scum to bottom of outlet tee or baffle 4 --------- --- How were dimensions determined? Tame measure and dip tube. _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Riser brings inlet cover within 6" of _gmde_Tank needs to be pumped and cleaned as soon asPosible. Solids are over 50%in tank. — Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ------ ----------- ------ Scum thickness --- ---- — ---------...—.--- Distance from top of cum to top of outlet tee or baffle ----------- Distance from bot om of scum to bottom of outlet tee or baffle --- ---- ---- Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address - ---------- --- — -- ---- ---- --- Phillip Brennan Owner Owner's Name - -- - ---- - — --- --- information is Centerville required for every __._.-. _______. __ __ MA 02632 _ A ril 20, 2015 _ page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: --- __ Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: ----- ------- —----- — gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -------- --- Alarm in working order: ❑ Yes ❑ No Date of last pumping: date ----- - Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address ----------- -------- --- ----- -- ---- Phillip Brennan Owner Owner's Name --- ----- -- information is required for every Centerville _- - - _ _MA 02632 _ April 20, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 01, ---- ---- 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.): One inlet, one outlet. 3_5' below grade. Needs to be replaced during system replacement. Pump Chamber(locate on site plan): Pumps in working order: / ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pum chamber, condition of pumps and appurtenances, etc.).- If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottin ham Drive Property Address - - - ------ Phillip Brennan Owner Owner's Name - - -- information is required for every Centerville-- MA_ 02632 _ Aril 20, 2015 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leachingits 1-6'X 6' w/ T of P number: stone. ❑ 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.): Liquid level 1' into 5' riser. System is in failure and needs to be replaced. Inlet line enters riser above liquid level. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth -top of liquid to inlet invert --------..-_. Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of constructign Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `a 111 Nottin ham Drive --- ------------ --------Property Address --- -- --= --------------- - -_ --.._. Phillip Brennan Owner Owner's Name -----" - — information is required for every Centerville — -- _MA _ 02632 April 20, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ------------ ------------ - I ---- ---------------------- Privy (locate on site plan): Materials of construction: - -------.-- i Dimensions Depth of solids —-...-- --—— ------ —------- Comments (note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Notting ham Drive------ —------- --------- ---— ---— Property Address - Phillip Brennan Owner Owner's Name -- ---- --- — information is required for every Centerville __--_ _MA 02632 April 20, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: i ® hand-sketch in the area below ❑ drawing attached separately l I ' i I , _) I I j 3 � � a ,0 0 1 t , I 0 1 i 3 S i t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 17 ' )1§ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 111 Nottingham Drive Property Address -- Phillip Brennan _ Owner Owner's Name -- - information is required for every Centerville _ _ MA 02632 Aril 20, 2015 _ page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: '5 - — 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: Se tp 9, 1985 __ Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain.- El Checked with local excavators, installers-(attach documentation) ® Accessed USGS database - explain: maps.massgis.state.ma.us/oliver_php You must describe how you established the high ground water elevation: Test hole in 1985 to 168" (elv= 57.2) found no ground water. Base of leach pit at elv= 65.6 per engineered plans_ _____ ______ Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts f= Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address ----- --------- ----- Phillip rennan Owner Owner's Name — -- — -------..---- -- ---- information is required for every Centerville _ — -- — — MA 02632 April 20, 2015 _ page. CityJTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1" Fl., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. qn u / Fill in please: DATE ;R APPLICANT'S YOUR NAME/CORPORATE NAME, D p /A ru ,M BUSINESS YOUR HOME ADDRESS: 111 Nnt£�rt 1�n Dr en e�✓� lle. vi(/{ 0alo 3 2- TELEPHONE # Home Telephone Number 08- 1 - 00, I-i" NAME OF NEW BUSINESS 4W P11,b 1/.q14 L ,tj,'K TYPE OF BUSINESS IS THIS A HOME OCCUPATION? V YES NO U V Have you been given approval from the building division? YES NO /( ADDRESS OF BUSINESS jM& A,L60V'G MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you i-n obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual ha ee info�natu d of t e per it req ments that pertain to this t ' p type of business. Authorizedre** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING UTHORITY) This individual has be, info ed t licensing requirements that pertain to this type of business. (� Authorized Signature** COMMENTS: TOWN OF BARNSTABLE LOCATION S&?Vwm# J— S� VILLAGE Wrr_trtAlQ ASSESSOR'S MAP&PARCEL 1N&PAtbER4S NAME&PHONE NO. t i k_ SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) (size) /OC�O NO.OF BEDROOMS S OWNER _Z.00,,r.el1 PERMIT DATE: C DATE: lO Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY M V f r 1 f f f f r !..! ! r r J /•!.f...F ! - / y f% 23 3 Water Service- Nottinaham Drive Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name . information is Centerville MA 02632 March 4, 2010 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way: Important: When filling out A. General Information forms on the �26 computer,use 1. Inspector: cr,!y the tab kcy to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return,, key. Septic Inspection Services Co Company Name _. r� 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State . Zip Code 508-428-1779 SI 12855 i Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Lcca!Approving,--thcrity (I P,�_-�--fAA r)6 March 4, 2010 I pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 10-58 Zonfrelli.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Tank is not in need of pumping at this time, leaching pit was half full at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ 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: ❑ Observation of sewage backup or break out or high static water level in the distribution box duet 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 10-58 Zonfrelli.doc-08/06 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, 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. 10.58 Zonfrelli.doc•08/06 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10-58 Zonfrelli.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0009pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section, D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 lance 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. 10-58 Zonfrelli.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part:of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank. inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 10-58 Zonfrelli.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ :No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — Last date of occupancy/use: Date — Other(describe): — 10-58 Zonfrelli.doc-08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 0'15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Last pumped over three years ago. - Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-58 Zonfrelli.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 4'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3'feet — Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ----------------------- ----------------- -------------------- ----- Dimensions: 8.5' long x 5.2'wide- 1000 gal. — Sludge depth: 3 — Distance from top of sludge to bottom of outlet tee or baffle 27 — Scum thickness 2 — Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 — How were dimensions determined? Measured — 10-5B Zonfrelli.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 cf 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in need of pumping at this time, liquid level was at bottom of outlet invert. Baffles were intact and clear. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 10-58 Zonfrelli.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 cif 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑, Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-58 Zonfrelli.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 )f 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ Teaching 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.): Liquid level in pit was 3-4 feet below inlet pipe with no signs of surcharge and no definite sidewall stains. 10-58 Zonfrelli.doc-08/06 Title 5 Official Inspection Forms Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer - Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 10-58 Zonfrelli.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Nottingham Drive -- Property Address John Zonfrelli _ _— Owner Owner's Name information is Centerville MA 02632 March 4, 2010 required for — State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) 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. J / ! / J / / / J I / J / / / / ? / / ! / / \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 23 3 R-x Viz' ater t. Service Nottingham Drive Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 111 Nottingham Drive Property Address John Zonfrelli Owner Owner's Name information is required for Centerville MA 02632 March 4, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: USGS topo map and town GIS. _ You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 35 and topo map shows property at el. 60 10-58 Zonfrelli.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1:5 of 15 �� - P �a � .use-� l CATION //1 El- AGE PERMIT NOToe 7 to 7 V`t i. LAGE �RNSTA LLER'S H A M E A C 0 R F S S U i L D E R OR OWNER DATE C 0 M P L I A CE ISSUED_`��� ��� 30 �- .�,y i �3 1/® No.....� ..... 7 Fxs T THE COMMONWEALTH OF MASSACHuSETTs BOARD OF HEALTH ..............OF.... f�J .T ..............1.�...... ......._........ Appliraitiun for Diupuuttl Works Tonutrudiun rrrniit Application is hereby made for a Permit to Construct 06 or Repair ( ) an Individual Sewage Disposal System at: c....,�:.. ..........................r (I.c;...>....... . ._:�' .f....................... Location.Address _or Lot No. ../ ....� � 14%� »ram: l✓1 ..__» r4� ....» r. .....T _C .�.. ............................»«.«.»........ ,. _ wner Address a ......-•---........ v. !.L1 5........-. .{ .( .?. ............................... ..................................................••-.............-•-•-•.......................... Installer Address Type of Building Size Lot....2!22....Sq. feet .-� Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building ........._.. No. of persons............................ Showers a+ YP g .........:...... p ( ) — Cafeteria ( ) 04 Other fixtures Design Flow...........11 ... ...............gallons r person pier day. Total daily flow............._. W gn ... ga per P p rl i y r� �.�..-- ..................gallons. WSeptic Tank—Liquid capacityl-��t gallons LengthO._.......... Width:....:.......... Diameter......." ... Depth.., '..` .. x Disposal Trench—No..................... Width.................... Total Length...............^..._� Total leaching area..._.._..._.........sq. ft. 3 Seepage Pit No..C>A-11_...... Diameter.... 1V Depth below inlet.....»-T.� Total leaching areal ' ?.sq. ft. Z Other Distribution box �) Dosing tank ( ) '" y... � .. . !.A ................................ a Percolation Test Results Performed b �..t'�l.t�...,.�1.�..��. Date..........._...............��� i Test Pit No. 1....�e-........minutes per inch Depth of Test Pit......41........ Depth to ground water../V-Q.............. LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil.......�:.���.... Off- LOCI;,v/ . .....`.?��—�.................. ......................O F. GG�� ................ .!....s ...._....�, W ................................... ....................... ....._.T ! ..... �,a-i.Lb. ................. ..... V Nature of Repairs or iterations AnsKtheaforedescribed n applicable.................:.. --•--•-------------•••-----............................................... ...............•-•----------.................................... ... .............----.-................................................. Agreement The undersigned agrees to insta Individual Sewage Disposal System in accordance with the provisions of:ITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl' nce has b 'ssu y the b�th. / Signed r :................ .. �.1 .... .. . . ....... . ... .. D to ApplicationApproved By...........: ................................ .............--.............................. ............. ...�:� Date 11 Application Disapproved for the Mowing reasons:........................................................................••••--.............. ................« ................••••........................-•••••----•....................•-•--............................................................._...................••..........__......................... D to Permit No........................................._---- . --._».... Issued............... ... ....... Date No.. �,,, ...... Fas................ .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...TJ...C,'. ....................OF........-c�,l�, .ICI:� ........... Applirtttiun for Diupuuttl Murky Tonstrurtiun 11rrmit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal System at: Location or Lot N. W Owner Address _ . ........................................... .._.... -........ ............................. Type of Building Size Lot..... �p Installer Address '. ....Sq. feet a �.a�t� U Dwelling—No. of Bedrooms.........--�_. ..............Ex Expansion Attic a •-•---•--•-•-• p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ......................... ......... ........................................ ........ W Design Flow........... Lp.......................gallons per person per day. Total daily flow............... .................gallons. W Septic Tank—Liquid capacity�Q':?.2gallons Length ?'.l".... Width 4`..� � - Diameter...."".._`-.`-. Depth2�..4 u x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No..h 0�!...... Diameter....-! I��Depth below inlet...�'�.�-.4 Total leaching area:t :`.?.sq. ft. Z Other Distribution box (>e) Dosing tank ( ) '"' Percolation Test Results Performed by `+e 1 Date... a ....................... ........ . ....... ... Test Pit No. 1....�4-......minutes per inch Depth of Test Pit.......?4........ Depth to ground water..:Win? —_—_ . G4 Test Pit No. 2................minutes per inch Depth of Test"Pit.................... Depth to ground water........................ O Description of Soil.......Z��...-?G'T OF__Gila rL l t .......... LJ ._........... ..s.. ,_ V ........_. tt�/ C��"At/1=C. c�; tJ,� Gt E,g�....... �,.. .._..?jr—. .... . i......._---•- ------•. -- --- ... =` r .... ..................•••----•-•-•••........ ...........•.....0�...�i(�,t}ICl.......t�._-1./�. ---�a-,-a..L.. ............................................................ Nature of Repairs or Alterations—Answer when applicable...................................._........................._................................. U � � ...... Agreement: .01h The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Ci4zo cc has b ssu y the b o t lth. igned r.... .. �.. ............................. .......... .... _. D to ApplicationApproved By............ ........................ ............................................. ............. .. ..�� Date Application Disapproved for thelowing reasons:................................•-----------•--................................................................. ...........-••............................................••---•--•---..............---...... ......... ......: D to PermitNo......................................................... Issued...................... Date --------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ..........r IZ l � . t (Intifirate of Tan' tP iturr THIS IS TO CERTIFY, That the Individual ew:a Dis oral System constructed ( ) or Repaired ( )gg�� p by-------•-•--•........•-••••.............................. !. .........A. 1 11V.---......................................:........................................:... Inatauer at.......................� 01...........10 .......!�/�. ?......D ! ............ .:�:v i I.).1�... ................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No:�!:�^.:- . I�_--:-? aPP I ... . .... dated.... :: '? - ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL yFUNCTION SATISFACTORY. DATE..... .. � ........ ........................ Inspector.w-,' / '„! •.. .............. .•--........----•----•----• ................... ..._ ._,. K..,._t .b,.,, ....� �,.,...4.p,..., .,. ... _.,y,. _ _,......_ .. .............. ....._.. .- � .� uP£A• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.....g6 6� 1... "7 ........OF.� �..+~ .....�� =.. FS�-. .... ..... ER ]Disposal Works Tuns#rudivit rrrmit Permission i hereby granted............. .........O o�2.F1' .,..... �.........!1� ...... to Construct or R tr an Inv ual S�wa�elf)isP9%y s�, G`V ( eP . ) T�I 11VV lh� y I atNo............ .................. .f?...................1..---.........................._�. ... .•--........._......................... ..... ._ ................... Street as shown on the application for Disposal Works Construction Permit No.(-7/. ...._/�............. Dated...... /i;../..................... / ................... ... ...' ............................... Board of health DATE..........................T///.........,-,..:�?.................�......� trw kl__P 0 X I77 'WASHED STO�jjt IJ T.V t 4 -V-vvf%;pr%EDSTONF_,--`T IOLE--'�7 c ftvl� �,�`WITNESS :MH.OUSE�MINAN.DAY -7 7i ,7 ITANK.A 5_4EFTIC TAN Kti�LEACH-; ACILITY G StDE :WAI'*l /D.'BOT �G/Do,Ile Tou'� IITER ENCOUNTERED (65 Z us LEACHING::NI-ESS. NOTED) - ANGLE MAP;.;:;"-:DATtjM(MSL3 t TAKEN*2.-M UN IC I PAL WATER PER FOOT 3.PIPE PITCH: -of I Ms AAS140 44 4.ocsmm LoAOINaFbR Aik��UN GROUNDCOVER OVER ALL SEWAGE FACiLIT;ESS'.16.PIPE JOINTS S.MIN. POPT(1)FT.SHALL BE MADE WATER-TlGtfi'�: Iu 'A iL I..OF MASS.`:',��,',', I47-trN.1 LLE IFENGINEER Kr-G.' R REF:Im s B ga-PREPARE0 FOR:1,,, JA ,��ENGINEERS'SURVEYORS V RS t�-(EXISTINGYZ n D TE'. .......... ' CENTERVILLE LEGEND PROPOSED CONTOUR t ® PROPOSED SPOT GRADE 100.0' ; ——98 —— EXISTING CONTOUR o + 96.52 EXISTING SPOT GRADE W— EXISTING WATER SERVICE Ro 40 TEST PIT pR 0 LOT # 104 PARCEL ID: 172/050 SITE AREA=I5,000± S.F. LOCUS MAP LOCUS INFORMATION PLAN REF: BK: 247 PG: 084 TITLE REF: BK: 24677 PG: 057 PARCEL ID: MAP 172 PAR. 050 I DECK 98 - I SEPTIC SYSTEM REPAIR PLAN o EXISTING 3 B R ------ o LOCATED AT: o DWELLING I 111 NOTTINGHAM DR. 96 CENTERVILLE, MA ` TOP OF FNDN `1 EL = 100.0 I t PREPARED FOR 94 \ , _ EXIST. 1 ,000 GAL BRENNAN SEPTIC TANK JUNE 12, 2015 ` I 1 98 ` wl ----- ------- ---i.---------i EX15T. 1 ,000 PIT ���, of 92 ,\ (see Note 10) o PD 9�y 96 No. 1140 h -_ N 01 20 1 I �, SANITA?RL �p�l 94 25.06— MEYER & SONS INC. 88 --�_ `-----`�� 92 --------__ 100.0' - P.O. Box 981 ---- --- ---- E. SANDWICH , MA 02537 nM PH. (508)360-3311 N O TTI N G H A M DRIVE 88 = � fax (774)413-9468 meyerandsonstitle5@gmail.com www.meyerandsons.com a SCALE 1"=20' SHEET 1 OF 2 J 1491 1 � ELEV. TOP NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS FOUNDATION BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (90.0-92.0) (Existing) VENT = 100.0 � F.G.EL: 106.1 F.G.EL: 97.80 F.G. EL: 93.0 rl 4 MAINTAIN 2% MIN SLOPE OVER LEACHING AREA p✓k-r SI� Q 2" OF 3/8" DOUBLE WASHED _ �p,I� F.G.EL: 96.42 L / D -,. . STONE OR FILTER FABRIC DOUBLE WASHED STONE 6" . w 4" SCH 40 PVC ®®®® O ®®®® A TEE'S ARE TO BE 14 s © S= 1% (MIUF. E ®®®®®®®®®® 4" SCH 4o PVC INV.89.50 2 DEPTH ®®®®®®®®®® INV.95.10 INV.89.30 4.s 2 X 8.5' 4' GAS PROPOSED DB-3 EXISTING OUTLET BAFFLE EFFECTIVE LENGTH = 25' .. .., :. DISTRIBUTION BOX INV. 95.35 (H20) INV. ELEV.= 86.38 t EXISTING 1,000 GALLON SEPTIC TANK of �sf9�y BREAKOUT NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING D R N M ELEV.= 103.50 PIPE INVERTS PRIOR TO CONSTRUCTION R TOP CONIC. ELEV.= 87.0 2) D-BOX SHALL BE SET LEVEL AND TRUE TO t1 1 INV. ELEV.= 86.38 :WE � ®® GRADE ON A MECHANICALLY COMPACTED SIX V ®®®®®INCH CRUSHED STONE BASE, AS SPECIFIED INEp ®®®®®310 CMR 15.221(2) ®®®®® 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK S4NITAR\p I BOTTOM EL.= 84.38 WITH 1500 GALLON SEPTIC TANK IF FAILED, (�,�1Z�j 3.75' 5 FT. 3.75' DAMAGED, NOT H2O LOADING, OR UNDERSIZED. 'C VV 4) INSTALL INLET & OUTLET TEES W/ SEPARATION 5.25 FT. EFFECTIVE WIDTH = 12.5' GAS BAFFLE AS REQUIRED SEPTIC SYSTEM PROFILE 5) PLACE SANITARY TEE IN D-BOX. BOTTOM OF TESTHOLE EL: 79.13 4 SOIL ABSORPTION SYSTEM (SECTIONI (500 GALLON LEACH CHAMBER) GENERAL NOTES: SOIL LOGS p : 14704 DESIGN CRITERIA - I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL # NUMBER OF BEDROOMS: 3 BEDROOMM BOARD OF HEALTH AND THE DESIGN ENGINEER. SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: MAY 28, 2015 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 - 310 CMR 15.405 (1) (8): WITNESS: DAVID STANTON, BARNSTABLE B.O.H. DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. 1) A 2.0 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING GARBAGE GRINDER: NO (not designed for garbage grinder) TO BE 5.00 Fr (MAX) BELOW GRADE VS REQ•0 3 FT. (H20/VENT PROVIDED) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFIL LED PRIOR Elev. TP-1 SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE Depth Elev. TP-2 _Depth " DESIGN ENGINEER. 91.8 0 90.8 0 LEACHING AREA REQUIRED: (330) = 445.94 S.F. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FILL FILL 74 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 90.05 21" 88.97 22" ENGINEER BEFORE CONSTRUCTION CONTINUES. A A 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. LOAMY SAND LOAMY SAND USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4' 10YR 3/1 tOYR 3/1 , , 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 89.64 26" 88.55 27" STONE ON ENDS & 3.75 STONE ON SIDES: 25 L X 12.5 W X 2 D THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF B LOAMY SAND B LOAMY SANG HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 1OYR 6/4 10YR 6/4 BOTTOM AREA: 25 x 12.5= 312.5 SF 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 88.3 42" 87.72 37" SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED C C TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. PERC ® EL. 87.0 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING MEDIUM SAND MEDIUM SAND DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req d CONSTRUCTION. 2.5Y 6/4 2.5Y 6/4 • 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND REMOVED PER TITLE 5. PROPOSED SEPTIC SYSTEM UPGRADE PLAN REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION Bo.13 140" 7s.13 140" 1 1 1 N07INGHAM DRIVE, CENTERVILLE, MA 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY PERC RATE <2 MIN/IN.NO GROUNDWATER(OBSERVED pC2' HORIZON) Prepared for: Brennan 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. Engineering and Survey by: SCALE DRAWN 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. • 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYER&SONS,INC. N.T.S. DMM 15. ALL PIPING TO BE 4' SCH 40 0 1/8"/FT (UNLESS SPECIFIED) to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX98f DATE CHECKED SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. EAST SANDW/CH,MA 02537 508-362_2922 06/12/15 DMM 2 of 2