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HomeMy WebLinkAbout0158 NOTTINGHAM DRIVE - HealthF-FA Nottingham Drive terville P 172 046 t I �r �J�aE�vctFp�oy UPC 10259 o- No. H_ 163OR .rnHs�`°� NABTINOB YN 1 1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. CityTown 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 A. General Information c\�\ on the computer, 1 J ` tN OF�Q�A ,����'. use only the tab �) ,. ':�ti'y key to move your 1. Inspector: cursor-do not James D.Sears JAMES '•�' use the return Name of Inspector v: key. CapewideEnterprises,LLC o� Company Name si,," r� �'I I I V 153 Commercial Street IHSPE%\\N nnruwtnH�\ Company Address Mashpee MA 02649 City town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification C, I certify that I have personally inspected the sewage disposal system at this adds ss and tlt t the C> information reported below is true, accurate and complete as of the time of the1rispection. Ue ins ction was performed based on my training and experience in the proper function and-m�aintenan&-of or.�..rs�ite sewage disposal systems. I am a DEP approved system inspector pursuant t Section 15.34t1 f t Title 5(310 CMR 15.000).The system: t w 03 ® Passes El Conditionally Passes I ElFa s - ❑ Needs Further Evaluation by the Local Approving Authority 7-10-14 ;hsp!=ctoes Signature Date y 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= onditions of use at that time.This inspection does not address how the system will perfornif in the future under the same or afferent conditions of use. t5ins•3/13 Title 5 Official Inspection Form:S if a Sewage Disposal System•Page 1 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Nottingham Drive Property Address Paul O'Donnell Owner owner's Name information is required for every Centerville MA 02632 7-7-14 page. Cityfrown 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): t5ins-3113 Title 5 Official inspection Form:Subsurface Sew age wage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '( 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. Cityrrown 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 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): 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 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 '< 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) I 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. 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than %day flow £,e111 A/e t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy�a 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. Cityrrown 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.] m ❑ ® 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 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 large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 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): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.tank D Box two chambers. Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2012-64,000 2013-31,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date 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: 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 �< 158 Nottingham Drive Property Address Paul O'Donnell Owner owner's Name information is required for every Centerville MA 02632 7-7-14 page. Citylrown 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: NA 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•3/13 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 M 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 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: Tank NA D Box and chambers 1999-Permit # 99-859. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 20"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: 1000 Gal. Precast H-10 Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M yy< 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. Citylrown 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge-Judge 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 at working level. Tank and covers at 20" below grade. In and outlet baffles. No sign of leakage or over loading: 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 t5ins•3113 Title 5 Official Inspection Forth: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 y� 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. Citylrown 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: El-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 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 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 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.): D Box is 16"x16"-32" below grade. Box is clean and solid Wone line out. No sign of over loading or solid carry over. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS.not located, explain why: t5ins•3113 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 158 Nottingham Drive Property Address Paul O'Donnell Owner Owners Name information is required for every Centerville MA 02632 7-7-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Leaching is two 500 Gal. Dry well chambers. Chambers are 34" below grade. Chambers are clean and dry w/stain line at 12". No sign of over loading or solid cant'over. No high stain line. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 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.): 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts v: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. Cityrrown 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: ® hand-sketch in the area below ❑ drawing attached separately ,4 13 07 3 -3 ❑ 3 13-�I= 30' 0 5� 0 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 158 Nottingham Drive Property Address Paul O'Donnell Owner owners Name information is required for every Centerville MA 02632 7-7-14 page. City town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N,® 12'+ Estimated depth toFigh ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting 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: Hand auger 12' no G.W.. Bottom of chambers at 5'+ below grade. Bottom of chambers at T above T.H.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 17 Y . • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 158 Nottingham Drive Property Address Paul O'Donnell Owner Owner's Name information is required for every Centerville MA 02632 7-7-14 page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 (3 ECO-TECH ENVIRONMENTAL THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION (revised 5/15/2000) TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 159 Nottingham Drive Centerville Owner's Name: Norma Smith Owner's Address: 159 Nottingham Drive ��Z Centerville Date of Inspection: 81nit 9, 2002 RECEIVED CC IVE® Name of Inspector:(Please Print)David D. Coug anowr, R.S. Company Name: Eco-Tech Environmental APR 16 2002 Mailing Address: 43 Triangle Circle Sandwich, MA 02563 TOWN OF BAKNSTABLE Telephone Number: (509) 364-0994 HEALTH DEPT. CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 of Title 5 (310 CMR 15.000). The system: _ l.�Zr_,,. X Passes IMAP . ..;. Conditionally Passes PARCH, • Oti(V Needs Further Evaluation By the Local Approving Authgrjl� 1 ,ate Fails Inspector's Signature �a�rvrnC. �"v�S Date: c q-t 200 2— 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 NOTES AND COMMENTS Inspector's Note=_> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 INSPECTION SUMMARY: Check A, B, C,D or E/ALWAYS complete all of section D: A] System Passes: X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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. Answer yes, no, or not determined (Y, N, or 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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 ' Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 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 s failing to protect public health,safety and 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. 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3) OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 D) System Failure Criteria applicable to all systems: You must indicate either "yes" or "no" to each of the following for all inspections I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no --X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. --X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. —X— Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS, cesspool or privy is below high groundwater elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form) No (Yes/No) The system fails.. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore, the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 large system considered a significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 ' Page.5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 Check if the following have been done• You must indicate either "Yee" or "No" as to each of the following• Yes No _X_ Pumping information was provided by the owner, occupant or Board of Health. _X_ Were any of the system components pumped out in the last two weeks? X Has the system received normal flows in the previous two week person? _2L_ Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined? (If they were not available as N/A) X Was the facility or dwelling inspected for signs of sewage back-up? X Was the site inspected for signs of breakout? X Were all system components, excluding the SAS. located on site? X Were the septic tank manholes uncovered, opened, and the interior of the septic tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum.? X Was he facility owner(and occupants, if different from owner) provided with information on the proper maintenance of subsurface disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: X _ Existing information. For example, Plan at the Board of Health. X Determined in the field(if any of the failure criteria related to part C is at issue, approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 " Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents I Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required Laundry system inspected (yes or no): n/a Seasonal use (yes or no): na Water meter readings, if available (last two year's usage(gpd):95 gpd: Sump Pump (yes or no): no Last date of occupancy: current COMiVIERCIAIJINDUSTRIAL& Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sqft/etc.): Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use:- OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS source of information: System not pumped in recent past(Owner) Was system pumped as part of the inspection: (yes or no) No If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: _X Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternate 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) APPROXE%IATE AGE of all components, date installed(if known)and source of information: Age_ 2+ years-Certificate of Compliance issued 12/16/99 to Wm E. Robinson Co (BOH Permit# 99-8591 Were sewage odors detected when arriving at the site: (yes or no)-m 6 Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 159 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 BUILDING SEWER_(Locate on site plan) Depth below grade: 1.5 ft Material of construction:cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints, venting, evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK: (locate on site plan) Depth below grade: 18„ Material of construction: X concrete metal fiberglass polyethylene other(explain) If tank is metal, list age— Is age confirmed by Certificate of Compliance_(yes or no): (attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle: 28 in Scum thickness: 2 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 13 in How dimensions were determined: Probe to ton of tank Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time- Liquid level at outlet invert Tank and tees appear structurally_ sound and f nictio ing as intended No evidence of leakage in or out GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction: concrete_metal fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 TIGHT OR HOLDING TANK: none (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/day Alarm present(yes or no):_ Alarm level: _ Alarm in working order(yes or no): Date of last pumping: Comments:(condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) D-box appears structurally sound with no evidence of leakage in or out Effluent level at outlet invert. No solids in tank. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 SOIL ABSORPTION SYSTEM (SAS):_X (locate on site plan; excavation not required) If SAS not located, explain why: Type: beaching pits, number beaching chambers, number —XJeaching galleries, number 1 beaching trenches, number, length beaching fields, number, dimensions overflow cesspool, number innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)' Sdils above leaching gallervappeared unsaturated. No evidence of surface 12onding, breakout, lush vegetation, or other evidence of hydraulic failure was observed CESSPOOLS: none (cesspool must be pumped at time of inspection) (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: none (locate on site plan) Materials of construction: Dimensions:_ Depth of-solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9,2002 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' (Locate where public water supply enters the building) NOTTINGHAM DRIVE I LOCATIONS A B EACHING W 18 ft 10 ft LGALLERY ° Z 2 22 ft 13 ft J 3 24 ft 19 ft W 4 28 ft 28 f t � I 3❑ D-BOX 2 SEPTIC no TANK i A B __,_7 3 BEDROOM DWELLING 58 NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 158 Nottingham Drive Centerville Owner: Norma Smith Date of Inspection: April 9, 2002 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 21+ feet Please indicate (check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed Observed Site (abutting property/observation hole within 150 feet of SAS) X Checked with local Board of health-explain: see below Checked local excavators, installers-attach documentation) Accessed USGS database You must describe how you established the high ground water elevation. Certification form on file with Board of Health, based on information from the Barnstable GI office, shows ground surface elevation to be at 56.8 f, and groundwater to be at 35 feet a 11 ,per CO�I�IO\1�:EAhTH OF MASSACHLSETTS s, EXECUTIVE OFFICE OF ENWIROINME\TAI.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION_' " ONE�ZNTER STREET. BOSTON hLA 0210r t61")292-550v TRi.'DY COX: Secre:a... ARGEO PAUL CELLLCCI DAVID B STRtt:S Governor Corntniss:oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addrest-58 Nottingham Dr,", Name of Owne►_JL1dy Porkka Centerville , MA Address of Owner: Date of Inspection: /. _14;. r- .. Name of Inspector:(Please Print) m. E. Robinson Sr. I am a DEP approved s erR inspector to Section 15.340 of Title 5(310 CMR 15.000) co,npsnyName: Wm• E . Robinson eptic Service Mailing Address: PO Box 10b9, Centerville , MA Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: /Pa Lsses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails r� Inspector's Signature: 4*11 s 1. - Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS revised 5/2/9E Page Iof11 � • r.. ,a.f nn Ge..,.:w,/Pann. lropertyAcMress158 Nottingham Dr. , Centerville Jwner Judy Porkka Date of Inspection: y INSPECTION SUMMARY: . Check 4,')B, C, of D: 6A. ►1SYSTEM PASSES: A 1 ha ve not found any information which indicateIs that any of tlie/Ailure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below:' COMMENTS: B. S1 S CONDITIONALLY PASSES: One or more system components as FI{e�F i'r#c,in the Condi�Qhi, Pass section need to be replgF or repaired. The system, upon completion11 of the replacement or repair,�s approved by tli 8gird of Health;*NI pass. Indicate yes, no, or not determined(Y. N,or ND). Describe basis of i nination in all instances. If "not determined',explain why not. - x The septic tank is metal, unless the owner or oparO ttbs:provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tan�C wasll installed"Within twenty 120)144is prior to the date of the inspection: or the septic tank, whether or not metal, is cramd,structurally iihi&d )d,shows Shc U&ntial infiltration or exfiltration, or tank failure is imminent. The system will pass i0i3O Lotion if the ex_istink '62kic tank ri�i kced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with aO�rbval of the Board of Health). broken pipets)are replaced F: obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). ThejpVaem will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFAift'SOWhi DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(corttin tied) Address:158 Nottingham Dr Centerville --: J.udy Porkka ate of Inspection: FURTHER EVALUATION IS REQUIFiEf1;bY 'iOARDVF HEALTH: Conditions exist which require furthar evaluation by the Board cow e' to clgfii6ne if the system is failing to protect the public health, safety and th4 environment. 1)°, SYSTEM WILL PASS UNEESS=WARD W`-OFJiEALTFI DETERMINES CORDANCE WIT 10 CMR 15.303(1)(b)THAT THE SYSTEM 1 IS NOT FUNCTIONIII _ ICH WILL PROTECT T 0IBLIC HEALTH ANdSAFETY AND THE ENVIRONMENT: CesAgpol or-privy is within 50`feet of surface water' i al or privy is within 50 feet of a borde>f4v"etated wetland or Wbelt marsh. 1 P t I i 1 Ste, 2L. 9LYSIEeILWILLEAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS ' CTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND-SAFETY AND THE ENVIRONMENT: t 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less,than 100 feet but 50 feet or more from 8 private water supply well, unless a well water analysis for coliform'bacteria and volatile organic.compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3,) OTHER h revise^ Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAdliress:158 Nottingham Dr. , Centerville Owner: Judv Porkka Date of Inspection:/X_/ D. SYSTEM FAILS: You mu indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes to i Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high-groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. P Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. . i E. LARG SYSTEM FAILS: a r You must i dicate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to p ealth and safety and the environment because one or more of the following conditions exist: 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 I 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) The owne or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of a Department for further information. revised 9/2/98 Paor4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Prop"Address: 158 Nottingham Dr. , Centerville Owner: Judy" Porkka Date of Inspection: _/G-9 Q1 Check if the following have been done:You must indicate either "Yes" or "No"as to each of the following: Yes/ No . Pumping information was provided by the owner,occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and­the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. Y _ As built plans have been obtained and examined. Note if they are not available with NiA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. i/ _ The site was inspected for signs of.breakout. i _ All system components,excluding the Soil Absorption System,have been located on the site. L _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: L _ Existing information. For example, Plan at B.O.N. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) The facility owner(and occupants,if different from owner)were provided with information on the propermaintenaaco-0f SubSurface Disposal Systems. revised 9/2/98 Page 5or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION /roperty Address:158 Nottingham Dr . , Centerville Owner: Judy Por ka Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 6sa g.p.d./bedroom. Number of bedrooms!d�§i�n):� Number of bedrooms lactual)d Total DESIGN flow--�— Number of current residents: Garbage grinder(yes or.no): 0 Laundry Isepa►ate system) (yes or no);,dd2, If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use Ives or no):Lo ` 1998 47, 000 gal. " Water meter readings, if available (last two year's usage(gpd): Sump Pump lyes or no)-k U 1.997 51 ,000 gal. , Last date of occupancy: 4. /4.-3 7 C MMERCIALIINDUSTRIAL: Typ of establishment: Desi n flow: qpd ( Based on 15.203) Basis of design flow Grea a trap present: (yes or no)_ Indus ial Waste Holding Tank present: (yes or no)_ Non-unitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Las�f date of occupancy: EER:(Describe) Late of occupancy: -- GENERAL INFORMATION PUMPING RECORDS source of information: s System pumped as part of inspection: (yes or no)k v If-yes, volume pumped/ b Ct Q gallons Reason for pumping: X.c I Pee, TYPE QPISYSTEM V 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no)LL C) ez v Y — Fs� revised 10/2j 9E Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) tra+"Address: 15 Nottingham ham Dr . Centerville g Owner: Judy Porkka Date of Inspection: S DING SEWER: (loc to on site plan) Dept below grade:_ Mater I of construction:_cast iron_40 PVC_other(explain) Diste ce from private water supply well or suction line Die ter Co ments: Icondition of joints, venting, evidence of,leakage,-etc.) SEPTIC TANK:_ (locate on site plan) �l Depth below grader / Material of construction: (.Concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age—/ Wage confirmed by Certificate of Compliance_(Yes/No) c i Dimensions: � 't it, p 6 Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: i Distance from top of scum to top of outlet tee or baffle:_ r Distance from bottom of scum to bottom of outlet tee or baffle:�� How dimensions were determined: 6 Ae 4- ;omments: (recommendation for pumping, condition of inlet and ou gpees or ball es,dep It of liquid level n relation to utlet invert, structural integrity, evidence of leakage, etc.) GR SE TRAP: hocat on site plan) ;I3epth£ low grade:_ Matetial of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensi ns: Scum th' kness: Distance from top of scum to top of outlet tee or baffle: Distant from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Com ents: (rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, ev ence of leakage,etc.) rev-J sed 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontiwied) Iroperty Addressl58 Nottingham Dr. , Centerville Owner: Jud.yi. Porkka Date of Inspection:/ /G—9� TI GT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) local on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) . Dime sions: Cap ity: gallons Des* n flow: gallons/day Al m present A m level: Alarm in working order:Yes_ No_ Dot of previous pumping: Cor ments: (coi dition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:V (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distnpution is equal,evid�e}�e of solids carryover, evidence of leak ge into or out of box, etc.) - /C/ fk > ;L-lam, - �3 PUMP AMBER:_ (locate o site plan) Pumps in orking order:(Yes or No) Alarms in orking order(Yes or No) Comments (note cond ion of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 page 8ortt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ropertyAddress: 158 Nottingham Dr . , Centerville owner:Judy Porkka Date of Inspection: /Ilk-/A/, NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater --2-'YFeet Please indicate all the methods used to determine High Groundwater Elevation: " Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe.how you established the High Groundwater Elevation. (Must be completed) 112/ w revised' 9/2/96 Page 11of11 TOWN OF BARNSTABLE C LOCATION �� r-(.Jy p ,�► �.� SEWAGE # �D s VILLAGE C ASSESSOR'S MAP & LOT !�� III INSTALLER'S NAME&PHONE NO.L�i te SEPTIC TANK CAPACITY I D u--<) LEACHING FACII.ITY: (type) 4 C (size) NO.OF BEDROOMS 3 BUILDER OR OWNER Pp, '-?, PERMITDATE: / 2-—/j:— `'7 COMPLIANCE DATE:)d- /G Separation Distance Between the: Maximum Adjusted Groundwater Table and Bohom 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 FaciliV/(If any wetlands exist within 300 feet of leaching facility) Feet Ir Furnished by x , , � 5 -�TOWN OF BARNSTABLE C LOCATION SEWAGE # VU_LAGE C c.'' ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. A SEPTIC TANK CAPACITY _10&_6 LEACH NG,FACIL=: (type) —4 C (size) NO.OF BEDROOMS BUILDER OR OWNER Pd:'02 PERMTTDATE: / 02- /( — 5 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted-Groundwater Table and Bottom of Leaching Facility Feet 'Private Water Supply Welland Leaching Fa ility (If any wells exist o6.site-or within 200 feet of leaching -�cility) Feet Edge of Wetland and Leaching Facili (If any wetlands exist within 3WJeet of leaching facility) Feet Furnished by 1 - 1 1 j 1 ' l :c !r NG1 �,f Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for 0iqu al *p 5tem Construction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 158 Nottingham Dr . , Centerville Judy Porkka Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E . Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 . Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable)new Title-5 leach system. D-box and. 2 chambers with stony all around.. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo d of ealth. 9 Signed Y 1 Date — Application Approved by e5 Date � �+ Application Disapproved for the following reasons Permit No. Date Issued "� r,r..✓ Lit, /� 'ti `� Fee THE COMMONWEALTH OF MASSACHUSETTS." Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Z[Pplicat on for �Digaal *raem Construction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 158 Nottingham Dr. , Centerville Judy Porkka Assessor's Map/Parcel / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E . Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) 1 Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable)new Title-5 leach system. D-box and. 2 chambers with stone all aroun .. Date last inspected: 102 6 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boprd of filealth. _ p d, Signed - Date ' 7 Application Approved by - Date _Ie'e Application Disapproved for the following reasons ti Permit No� �' — � — /----- Date Issued — —————— —————— THE COMMONWEALTH OF MASSACHUSETTS Porkka BARNSTABLE, MASSACHUSETTS Certificate of Comp ance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 158 Nottingham Dr. , Cemtervl le as een constructed in accordance with the provisions of Tithe 5 and the f Disposal System Construction Permit No9l - dated 4? �" ram' Installer . E. Rob ins on r. r Designer The issuance of s pertrut s�all"of be construed as a guarantee that the s�stem will function as di 'es Date I/l 'mil Inspectorta' v (�f No. ------------------------------Fee 5 0 THE COMMONWEALTH OF MASSACHUSETTS- PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Porkka igpogal *p5tem Construction Permit Permission is hereb ,ggranted t Construct( Repai U rade )Abandon( ) System located atlt3 Not�ingnam D�r. ,, G� n�Cevil�e and as described in the above Application for Disposal System Construction Permit.The applicant recognizes 's/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 thisormit. � . Date: � � `"' /�°� / ,� Approved b i 1/6199 . NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I William E . Robinson,S,Ihereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 158 N a t t i n Qham Imo.-,—GQ-nt e=v!�q:e meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. X" • The soil is classified as CLASS I d the percolation rate is less than or equal io minutes per inch. • There are no wetlands within '0 feet of the proposed septic system _ • There are no private wells v'thin 130 feet of the proposed septic system • There is no increase' flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma.�imum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A and B SIGNED .- r DATE: [Sketch proposed plan of system on back]. q:health folder:Bert R6 4 ..rZ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �'� ifn_ bZl Town OF..Barnstable .................. .-....._........... App iratinn for inpusal Marks Tnnstrudian rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Nottingham Dr.---Centervill&......... ...... .Lot... ...1.'.... ..... ... . .......................................... tion-Address Ashley Dr, CerftidrVille Normes t Homes �'f�c. --- .... ......----.............................................. W James Dolloway Owner Five Corners Rd�ieEenterville a --------------•---•-•-•-----------•----•----••••---------.....--•--•-•----------......----••--••-- •---........-••-•---..............-----••----......-•-••••--•-•-•-...............---•••----•-•---- Installer Address Type of Building Size Lot.......1.5000........Sq. feet Dwelling—No. of Bedrooms..............3...........................Expansioi3 Attic ( ) Garbage Grinder ( ) aOther—Type of Buildinjl 0qO- �;frame_. o. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----------•• . . ------.---•---•----•-••--•-------•-•-••-•-•-------•-•--. ... --- -- -- - - -----Design Flow------------------• • 0 . a 300 W g gallons per person per day. Total daily flow W WSeptic Tank—Liquid capacity!.000gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... W}}'dt ...g ®.. Total Length.................... Total leaching area................_..sq. ft. Seepage Pit No..................... Diameterbx�Pal. Depth below inlet.................... Total leaching area.. � ........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by....................................................................•---- Date........................................ Test Pit No. 1------ per inch Depth of Test Pit.................... Depth to groundwater..______........_....__. w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -----------------------------------------------------------------------------------•---•--•--•-•---.......................................................... z a & Description of Soil--- s----nd------ --- .------------.ravel .._...... x U -----------•--••------------- -----------------•-------------•-•--------------------•-••--------------------------•-----...-----------------------•----------------•---•-.....----..........----.. W U Nature of Repairs or Alterations—Answer when applicable...__........................................................................................... -----•---------------•-•---------•-----••--------•--•--•--•---------•-•-----•---•---•-•-----......-•-------•-•-------------•--------•-........•--------...-•-•----•-•-----•-••----------...--••••....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has eissuedhe board of health.e / � l..... ------------.... Date A lication A roved BPP PP Y ,� .. ........ ----•- �f........ Date Application Disapproved for the following reasons:------ ---------------------------------------...................................... .........-•-•••...............••----------------------••---•••--••--------•-•---•----....---•------••-----••--•---•-•-•--....-••--•---••-----•-•-----. ................................................. Date Permit No--------------•-----......•--........---.......---••---- Issued.........-.......--- L ....--•------•--•.................. Date • THE COMMONWEALTH OF MASSACHUSETTS BOARD OR HEAL`fH bw .................oF..104 c ...... Appliration for Ui#ivs,al Warho Tomitrudion Vamit Application is hereby made for a Permit to Construct ( ) or Repair (, ;) an Individual Sewage Disposal system at . �t .xag} . :. .•.. e ! e.. ......... ... .. .1.1.................. ....................... cation Address ..... or Lot No ��a'mest Homes roc. ash...e�..D�....C®�ate�°�€�......e ................... ... ....... W James Dollowa owner ... Five Corners Rc�lre�enterville ................. ....Installer.•..- ........................ ...... ............................................Address............... ........ ..................... Type of Building Size Lot...:__:�.SQ .......Sq. feet a Dwelling—No. of Bedrooms ............. .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building'Mgd .�MV3 . No. of persons .b.................. Showers ( ) — Cafeteria ( ) d Other fixtures :--•.................•-------------•------------------ Desi n Flow........................5Q_. ... allons er person per day. Total daily flow.....:-.... g.......................... W .g g P P P Y Ygallons. � Septic Tank—Liquid capacity A gallons Length .............. Width.... ..... Diameter.....--......... Depth.............--. Disposal Trench—No.............. ..... W tl}, $ Total Length..-........ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter ....,._p_....._. Depth below inlet.."..:.............. Total leaching ared34� ........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.----•-•.................•-•-•---•-•-•------ Date :..... Test Pit No. 1...... --...minutes per inch Depth of Test Pit.................:.. Depth to ground water..-..------.--------.--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit......--............ Depth.to ground water........................ O i�Xla d6 'a�'� Description of Soil.................... ---------------------------- ------------------------------------------------------------------------------------•-----•--------------•----------......-----------------------------------........-----•-- V Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...............................................................-........................................................................................................................................ Agreement: The undersigned agrees. to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in- operation until a Certificate of Compliance has been ssued by the board of health. Si led. ,. 1 .....................------ •. --;..... ------------- Date Application Approved BY-....-. r� nL:-.... ---- ......... •--........... Date Application Disapproved for the following reasons:--•-- .... ---•------------------------------•-------------................Da .---•-......•••- .. ....................•••---.......•-•------•...•-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable e ..........................................OF............I.............................I.......................................... (lprtifirFatr of TarA tiatta THIS IS TO CERTV. FY T] Individual Sewage Disposal System constructed ( or Repaired ( ) affi�s f.]4��10&�a'y------•--•---- -----•-- bY ..... .................. . . at.---••--------------•-------------....+�t--1' 1FFOttingYtaz�t Dr'�t nter`�r�l�� - has been installed in accordance with the provisions of Article XI of The State Sanitary Codd as described in the application for Disposal Works Construction Permit No----------------------------------------- dated..-� --2.,��`j.-��- ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector............:........................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town oF..Barnstab e No....2. .3..... FEE...: Rigao a1 ur (�pr �trti a� rrtttit affi®� o Od�� Permission is hereby granted.--•••-------------••-•--• •-•----••-.--•••-•••-••-•----•-•••-•-•........-•-•-••................•••--........•-•-.................... to Construct ( ) or RepEer j 1anjn} i� Ijyfia �ispo�Ats4%ill®j9 'at No.•-•..................................•......................._..................... ...... .................................................................. Street as shown on the application for Disposal Works Construction PLg .r. ......... Dated..... _ !- ._._1 ......... • -�-"E'� �� `"�a ..�- Board o th DATE ...... r' FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ' -