The URL can be used to link to this page

Home My WebLink About0263 NOTTINGHAM DRIVE - Health S3. Nottingham Drive i Centerville P A = 171 047 I Ow ford NO. 1521/3 ORA y, 10% 4 A c Commonwealth of Massachusetts oq-j- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , yy b� 263 Nottingham Drive ' Property Address Tina Vaughn Owner Owner's Name / information is Centerville V Ma 02632 7/20/2020 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. Please see completeness checklist at the end of the form. Important:When Titling out forms A. Inspector Information S14 lL490 1 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane ,. Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Humber B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 . (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails .� `t 7/20/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the_system owner and copies sent to the buyer;aif applicable, and the approving authority. . Please note,.This report.only describes.conditions.at_the time of inspection.and-under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown 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 263 Nottingham Dr Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box, 1000 gallon precast leach pit and 2 precast leaching 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. D Y ❑ N ❑ ND (Explain below): 15insp.doc-.rav,7/28/20.18. Title.5.Official,Inspection..Form:Subsurface,Sewage.DisposalSystem.•..Page.2.of 18. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the'Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR %303(4)(b)that the system is not functioning-in a-manner which-will protect publiic health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;. 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown 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 determirve 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 ❑ ® 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c O� Commonwealth of Massachusetts _ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year 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 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. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ 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 disposat systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System form- Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 per. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes tD No Seasonaluse? ❑ Yes 0 No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 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 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ED No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown State Zip Code Date of Inspection 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. El Other(describe): Approximate age of all components, date installed (if known) and source of information: original system with 2 leaching chamber addded 2000 Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): Depth below.grade: 1.5 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.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 4� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: 0 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 gallons 5, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2° Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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 andoutlet 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for.every Centerville Ma 02632 7/20/2020 page. Cltyrrown State Zip Code Date of Inspection 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): 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.): Distribution box was replaced for inspection permit#2020-216 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Fora-Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *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: 0 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owners Name information is required for every Centerville Ma 02632 7/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Original precast leach pit was left connected when system was repaired in 2000. Pit was video inspected and found dry. Leaching chambers were video inspected and found with 6" standing water and no signs of past hydraulic overloading 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration I 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. � 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown 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 Q� o t ✓�1 3 2 6 Z 13 EpAZ 3f 3 '31_ 2 °6 A3 ys 133 38 Ib 5� yy 3s 6 � Sy t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 ' Commonwealth of Massachusetts ;? Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 263 Nottingham Drive Property Address Tina Vaughn Owner Owner's Name information is required for every Centerville Ma 02632 7/20/2020 page. Cityrrown State Zip Code Date of Inspection 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 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ' - TOWN OF BARNSTABLE LOCATION l0 3 &r yAM ox SEWAGE #X,00a— H3 J VILLAGE C eA/'�.Pe V///e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. T. /P I .4 C R Pie .4 s ow SEPTIC TANK CAPACITY Z Qd 0 -4 10/1 [} 40 LEACHING FACILITY: (type)11CA 6 W C AAt A At&(size) NO.OF BEDROOMS BUTEtYM OR OWNER PERMITDATE: '"`` e�COMPLIANCE DATE: 71" o 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�eaching'facility), Feet Furnished by F �- O � �. �� d s . ., � � �� l0I �� s � � i ' y� ' .: �� I `tt \'�'�� ` �\ . �/ � �a�, . . • _�- tip:�.�,• - .� TOWN OF BARNSTABLE LOCATION Al /t'l�'{74i'7g �ihrn /�fR c t c SEWAGE # VILLAGE ASSESSOR'S/MAP & LOT INSTALLER'S NAME& PHONE NO. wAA .T�s�r�vt7dtit SEPTIC TANK CAPACITY. LEACHING FACILITY: (type) .fiillS (size)J2;e,6,4,/�' ,^-t b NO. OF BEDROOMS - R OR OWNER .,I e_ 60// k-14 DATE: COMPLIANCE DATE: Separation Distance Between the: t , 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 _ _ ;�:�== � i 32'. i a � �� , � _ _ cr, ,�� No. V► Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS applitation for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair 4 Upgrade( ) Abandon( ) ❑Complete System dndividual Components Location Address or Lot No. a,(„3 o�� (�( Owner's Name,Address,and1 Tel.No. Assessor's Map/Parcel —(� CJ�"��v\1� �\\1\C\ V C Q h n Installer's Name,\Add ss,and el.`g. signer's Name,Address,and Tel.No. 1'3 ��d �I�-C h,cL7�. c Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0 c i� 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 Board of Health. ed Date J Application Approved by Date Application Disapproved by Date for the following reasons r Permit No. Date Issued 1tY No.Aa Fee �. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS . gppliration for. Disposal *pstettt Construction Permit x' Application for a Permit to Construct Repair Upgrade Abandon Complete S stem 'Individual Components PP ( ) P (� Pg ( ) ( ) ❑ P Y P Location Address or Lot No. �(o p�� (a(' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel V—)I...( Installer's Name,Address,and Tel.No.s Designer's Name,Address�Iand Tel.No. Type of Building: ti Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ' Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title - t a Size of Septic Tank J Type of"SAS. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) z n [t • �c�,.� 4� 1.o Cl �� _ ±I Date last inspected: a,. 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 Board of Health. q Si' ed 4112—Date Application Approved by ,�� —_ _` Date /1 Application Disapproved by I ! Date for the following reasons 1Y A l r Permit No. / / Date Issued ��. L. --- ----------- ------- W - - - - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( V/) Upgraded( ) Abandoned( )bye c'a f_l `' at. it= nl ran �,.fi�nn �� .�# has been cons cte in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No , �,rated _-Installer C.�S KlC (<�n Designer t_. #.bedrooms Approved design flow„g ' . gpd The issuance of this per-mitt shhaa l'nnot-��be/c�onstrued as a guarantee that the systemill function as de§g`n d. - Date / >,LSD✓% . i Inspector No. W)4,)'' � Fee " ` THE COMMONWEALTH OF MASSACHUSETTS -PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS �1$tIDBaY 6pstetn DnstrULtion permit Permission is hereby granted to Construct( ) Repair( UpgradeO Abandon( ) System located at �o �� +.�Ca` t 1 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:Cons ction must be completed within three years of the date of this permit. , p J )r Date �/� 1- Approved by� — /g COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS V DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED 5�a SEP 4 2002 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION `l Property Address:263 Nottingham Drive Centerville Owner's Name:Joe Celleda Owner's Address: Date of Inspection:8/22/02 Name of Inspector: Timothy Lovell Company Name:Accurate Inspections Mailing Address: 550 Willow Street W.Yarmouth,MA. MAP Telephone Number:508-771-3700 PARCEL , 4� CERTIFICATION STATEMENT LOT :...W. 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: X_Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signatu e: Zg� Date: 8/22/02 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 ****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. \ C Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:263 Nottingham Drive Owner:Joe Celleda Date of Inspection:8/22/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _z I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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. N/A 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 infiltration 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: N/A Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s)are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: ,N/A 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: Page 3 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:263 Nottingham Drive Owner.Joe Celleda Date of Inspection:8/22/02 C. Further Evaluation is Required by the Board of Health: _N/A 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: _N/A Cesspool or privy is within 50 feet of surface water N/A_Cesspool or privy is within 50 feet of a bordering vegetate 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: _n/a_ 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. _n/a The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _n/a_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _n/a— 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 263 Nottingham Drive Owner:Joe Celleda Date of Inspection: 8/22/02 System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: 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'/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 ground water 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 at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 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: N/A 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 H 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 "ryes"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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:263 Nottingham Drive Owner:Joe Celleda Date of Inspection:8/22/02 Check if the following have been done.You must indicate"yes"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 previous two weeks? _x _Has the system received normal flows in the previous two-week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? _x —Were as built plans of the system obtained and examined?(If they were not available note as N/A) _x_ _Was the facility or dwelling inspected for signs of sewage back up? x _Was the site inspected for signs of break out? x _Were all system components,excluding the SAS,located on site? _x_ _Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? x_ _Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no x `Existing information.For example,a plan at the Board of Health. _x_ _Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:263 Nottingham Drive Owner:Joe Celleda Date of Inspection:8/22/02 FLOW CONDITIONS RESIDENTIAL 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: Does 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):_no_ Water meter readings,if available(last 2 years usage(gpd): Sump pump(yes or no):_no_ Last date of occupancy:_Current COMMERCIALANDUSTRIAL n/a Type of establishment: Design flow(based on 310 CMR 15.203): gel Basis of design flow(seats/persons/sgfft,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: Pumped last during repair 7/25/2000 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/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: 7/25/2000 Were sewage odors detected when arriving at the site(yes or no):_no_ Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:263 Nottingham Drive Owner:Joe Celleda Date of Inspection:8/22/02 BUILDING SEWER(locate on site plan) Depth below grade: 2' Materials of construction: cast iron _x 40 PVC_other(explain): Distance from private water supply well or suction line: 50' Comments(on condition of joints,venting,evidence of leakage,etc.): Joints look fine no evidence of leakage venting is ok SEPTIC TANK:_x (locate on site plan) Depth below grade:_1' Material of construction:_x concrete_metal_fiberglass_polyethylene—other (explain) If tank is metal list age:_Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000 gallon tank Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle:_38" Scum thickness: Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_14" How were dimensions determined: in the field tape 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.): Pumping recommended every 2 years,no evidence of leakage,inlet and outlet baffles in place,liquid level at invert out GREASE TRAP:_Na (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.): Page 8of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:263 Nottingham Drive Owner:Joe Celleda Date of Inspection:8/22/02 TIGHT or HOLDING TANK:_n/a (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 alarm and float switches,etc.): DISTRIBUTION BOX:_x(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.): Distribution box level liquid level at invert out,no evidence of solid carry over,no evidence of leakage PUMP CHAMBER_n/a (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.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:263 Nottingham Drive Owner:Joe Celleda Date of Inspection: 8/22/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type Leaching pits,number:_ x Leaching chambers,number:_2_ Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 2-500 gallon chambers with Mrox 3'stone surrounding them no damp soil vegetation normal no evidence of hydraulic failure CESSPOOLS:_n/a (cesspooI must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:—n/a (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 263 Nottingham Drive Owner:Joe Celleda Date of Inspection:8/22/02 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. Back of Home ...................... ......... 32> 22' 35' f 32 1000 gal tank 500 gal. Chambe 45' 40' DB Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:263 Nottingham Drive Owner:Joe Celleda Date of Inspection: 8/22/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_19'_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _x Accessed USGS database-explain: Plate 2 You must describe how you established the high ground water elevation: Information provided by Cape Cod Commission Index well readings Well#Al W-230 August 2002 reading 25.3 adjusted to 18.9 Topo bottom of system at approx. 24.0 s No. 19 �. �� ' Fee $ 5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE., MASSACHUSETTS l� ZippYication for 30i5pont 6potem Construction Permit Application for a Permit to Construct( )Repair�[X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 263 Nottingham Drive Owner's Name,Address and Tel.No. Centerville,Mass. 02632 Patty Stuart 263 Notting Ham Drive Assessor'sMap/Parcel Q Centerville,Mass. 02632 Installer's Name,Address,and Tel.No. 5 0 8-7 7 5—3 3 3 H Designer's Name,Address and Tel.No. 5 0 8-7 7 5—3 3 3 H J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3/1 1 0=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existinq 1 000 & box Type of S.A.S.1 —1 000 LP existing Description of Soil. Loamy sand to boney sand to fine sand. Nature of Repairs or Alterations(Answer when applicable)Adding two 500 gallon leaching chambers to the existing septic system. Chambers will be packed in 4 ' of 11" stone. 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 issu by this Bo o Health. Signed Date /1 /0 0 Application Approved by Date 7- 3-5-,D(I Application Disapproved for the ollowi g reasons Permit No. 3 Date Issued Fee $ 50100 . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I/ A Yes z PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for -Miopogar bpelem Construction Permit Application for a Permit to Construct( )Repair4XX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 263 Nottingham Drive Owner's Name,Address and Tel.No. 63—ftttingham Dr V Centerville,Mass. 02632 Patty Stuart 263 Notting Ham Drive Assessor'sMap/Parcel Q Centerville,Mass. 02632 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8-7 7 5-3 3 3 8 H.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: ' Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3/1 1 0=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Exd)sting 1 000 & box Type of S.A.S.1-1 000 LP existing Description of Soil. Loamy sand to boney sand to fine sand. Nature of Repairs or Alterations(Answer when applicable)Adding two 500 gallon leaching chambers to the existing septic system. Chambers will be packe packed in 4 ' of 1�" ston4a. 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 B d of Health. Signed Date 7/17/0 0 Application Approved by Date 7- aL, Dn Application Disapproved for the ollowl g reasons Permit No. _ 34?2,">- 3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certif irate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed~( )RepairedYXX)Upgraded( ) Abandoned( )by J.P.Macombere& Son Inc. at 263 Nottingham Drive Centerville,Mass- Has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Now- .3 7 dated Installer J-P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc. The issuance of this permit shall not be construed as a guarantee that the says will function a desig fe-d. Date �' ! �� Inspect No. .J ? Fee$ 50.00 THE COMMONWEALTH Of MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopooal *pgtem (Cow6tructio' Permit Permission is hereby granted to Construct( )Repair�X )Upgrade( . )Abandon( ) f " Systemlocatedat 263 Nottingham Drive' Centerville,Mass. ,' a ' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/,her duty'to comply with Title 5 and the following local provisions or special conditions. 'f Provided:Construction must be completed within three years of the date of this permit. r Date: :2 Approved by 4 i f t, s l/6/99 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) Joseph P.Macomber Jr., hereby certify that the application for disposal works construction permit signed by me dated 7/17/0 0 concerning the property located at 263 Nottingham Drive Centerville,MAmeets all of the Mowing criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in 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 maximum 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 M 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) 3 B) G.W. Elevation +the MAX. High G.W. Adjustment. 7 DIFFERENCE BETWEEN A and B SIGNED : J DATE: 7/1 7/0 0 (Sketc posed plan of system on back). q:health folder ccn . � 0 O / TOWN OF BARNSTABLE LOCATION .x oa 3 /VQ-f-11/N r. IYAM ox. SEWAGE #,Z-aeO— y 3 VILLAGE C 2N'Teg V 1 le ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO: J' P,,44 Q C 6 M R eX -, S o1v SEPTIC TANK CAPACITY 1 d a o •4 P/7 p /17 LEACHING FACILITY: (type)1—l B I.v CAV A Al I3 PX (size) NO. OF BEDROOMS BUTEDER OR OWNER PERMITDATE: -7 / '?"`2(7,rVCOMPLIANCE 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 aching facility) / Feet Furnished by +,� 13Ile r T71 i / l 0 =g eba ............................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 77 077 - ............OF........ .................................... ,2 ppliration for Diipaoraal Vo Tomitrurtion Frrutit Application is hereby made for a Permit to Construct �) or Repair ( ) an Individual Sewage Disposal S stem '^ T y 7/at: aion-pd res / ................... T................ ........•/y/"�/ ------(-rj--!..1..�..--------- --- T ..- -'--h-TI --- T. Owner r A ress a 1,l_ _.... �.._.._.... _611.'<. ...... /l?Y1r �7-------- - �.. ......................................... Installer Address dType of Building Size Lot__/,�_ .�Q0----Sq. feet U }} U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (17 aOther—Type of Building ............................ No. of persons___--_-_____-__-.___-_______ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... .. W Design Flow................................I...........gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity..�.Q40.galions Length................ Width................ Diameter_-.__.__-____-_. Depth................ xDisposal Trench—No..................... Width_..._-___-_-__-___-_ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......./.,--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ) `"' Percolation Test Results Performed by._--__--_--. ...__/ .�.�.�=.�. ................. Date_._. __ _ l l a Test Pit No. 1................minutes per inch Depth of Test Pit............. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... ...........................................................=...............................................................•----............................ 0 Description of Soil........................................................................................................................................................................ x U ..............••---•---......••-•----.......-----------•------......_....--•------...----....._.............---------------•----------•--...------•----------------........----•-......•....------ w x ---------------------------------••-•--------•-----•--••-----------•--•---------------------••-••----•----....•-------------------------••-------------•--------------------- ........................ UNature 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:iT` y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a ifi of Co liance has be sued by he board o liealt ne /_ p� d� `......_.. •- ate -........ Application Approved By........ / � ---------------- Date Application Disapproved for the following reasons.----•-••------------••••------•------•----------------------•--••------------------------------•------••-••-•--- -------------------------------------------------------------------------••--•----------••-•-••-------------•------------------------------------------------------------.............................. Date PermitNo......................................................... Issued....................................................... Date l Qy 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------...r ............OF........ ------------- Appliration for Disposal Works Cfnnstrurtiun Prrutit Application is hereby made for a Permit to Construct (/ or Repair ( ) an Individual Sewage Disposal system,a64 ............. . l J L on- dress or o •. a / �Qw er l /t f' Address ... ............................ Installer Address «-� Q Type of Building Size Lot-_/J�.€f�-QS. ..Sq. feet Dwelling—No. of Bedrooms........._______________•--___----_-Expansion Attic ( ) Gar age Grinder 0 6) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- W Design Flow...........................................gallons per person per day. Total daily flow...........................................gallons. WSeptic Tank—Liquid"capacit 400gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—N . .................... Width------------------_ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... --------- Diameter-------------------- Depth below inlet.................... Total leaching area---...............sq. ft. Z Other Distribution box ( ) Dosing tan�._j Percolation Test Results Performed by............. ..._ '_ .. _1f......._......... Date....r e ..... 1 7,F/ / Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to.ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................... a ------------------------------------------------ •-•..... •••--- ••---------------------•------------------------------------------------------------------ 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------•---. V ....•-••••••••••-••••-•••••-••••-••••••-•••••••-•--•-••-•-••---•-•-•-•-••-••--•--••••..........•-••••••••••--•-••-••---••-••--••-••-•-•-••----------.................................................. W ---- ----------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•---- UNature 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 ITT . "j of'fheY5tale S nitod`eTh�,undersigned further agrees not to place the system in operation until a ifi" of Co liance has bee sued by he board o healt Si n. ..... t� r�"" Pate Application Approved By...... , : '. °____ .. , !' Date w Application Disapproved for the following reasons:;---_/.'----------------------------•-------------.------_----•.---------------•--------__�::~_::._......._.; 11 *' K ......................................................................................................................................................................................................... Date PermitNo.............................---------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �d "` "" p .,w ..... G?l a.•-'.:..........OF....... C✓ ............................... Trrtifiratr of T. mptinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( r Repaired by---------------- ---.. ..-------------------------------•--------.............................................. Installer d � ................•-----.......---•------•------------ - � at � }'------...... . � i� �1 ------------- has been installed in accordance with the provisions of T �, z ` of The State.Sanitary e escrabed in the application for Disposal Works Construction Permit N 1214)________________ da.ted__... _�F_ ___ _______.____...._.__....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST D AS A GUARANTEE THAT THE SYSTEM WIL F`UN/t ION SATISFACTORY. DATE.......1. ...................................................... Inspector...... ................................. ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH FEE...7_3A.1.......... Disposal Works Twnnstrnrtion rrntit Permission is ereby granted...---�`--------- . .................................................................................................... to Construct or Repair ( ) an Individual Sewage Disp al Syst atNo...........................................ei•- ---•-•-••-- Street as shown on the application for Disposal Works Construction xr-r�' No..................... Dated.......................................... _ 7 "� --------------------•--------------- Boar pYt1;alth L. DATE. / ',1------------------------------------ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS f�. W FLTL2t 4 3 �� n1 Q 1 2 drv. P� aa 43 7G.8 oc 7W"z� D477 F 38'+ PA"z---o DAUV9 � � — NTH 1 Lor #/zo 4 No7-r- an/ ASSuHo D D�tTLi's CERTI FI ED PLOT PLAN LOCATION C4W7VZ vi c;4& ,MA 5 S; J' EDWARD E. KELLEY SCALE . �.�`. .�o�. . . . DATE !?:� Z3 iggi .. CUMMAQ�JID, �;iASS, 02b37 PLAN REFERENCE .43Z-7,,VC Lqr, SNofuni pn/ /9 cF Bd': Z4 7 /^, gift . . . . I CERTIFY.THAT THE xi57-InrG Fauw.a,��o v SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF . . G. . . .. ... . .. WHEN CONSTRUCTED. C�4GBE7- P�?9LT�/ T,-44,ST DATE /7W—. 23 AV PETITIONER: 1NE5T �''yA.�.w/S/oaa�' M�55. Gre f+. REGISTERED LAND SUR1 EYOR f TOP OF FOUNDATION CONCRETE COVER ` • CONCRETE COVERS 4 CAST IRON • PIPE-(OR 12"MAX. "MAX. "'r"'r'' • 4"ORANGEBURG(OR EQUIV.) EQUIV,)- MIN. PIPE- MIN. LEACH PITCH 1/4"PER. PITCH I/4"PER.FT. PIT PRECAST o'e "--INVERT a LEACHING ` a EL.. •.�� ... INVERT NVERT e . a•,' PIT OR SEPTIC TANK EL .73•d j DIST EL.73.35 : �_ EQUIV. a INVERT BOX -� p; ••• ./coo .. GAL.. INVERT �' ;•• " •• v w a 0• .�. 3/4 70 11/2 `e EL..73,d6 ,73 Sz INVERT w �. ..... �a �. WASHED w STONE .-PROFILE . --,OF--.- -----_. .._ ___. .---.._ GROUNO WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE ti' SOIL LOG WITNESSED BY DATE . .Z3/y8/ TIME.1130,9rI PA?!L, C'. •/'It�,229 L, BOARD OF HEALTH TEST.HOLE I TEST HOLE 2 rJs}S ,L--- XE? 4-y RC. . ENGINEER ELEV.. .7S 70 . . ELEV•:��"Go. . . DESIGN DATA : 3s„ Z¢ 11 4�" Fitiit�Ss+..D NUMBER OF BEDROOMS Fiti/e- Sel+vA TOTAL ESTIMATED FLOW . . 33n. . . . GALLONS/DAY C2niE2 Ceav�Z. ___ ,?L„ BOTTOM LEACHING AREA 78 So . . SO.FT./PIT SIDE LEACHING AREA . . /8�'So . . SO.FT./ PIT S/.YivD SAID GARBAGE DISPOSAL Nvnl��.(50% AREA INCREASE) TOTAL LEACHING AREA . . .Z47 4-P. SQ.FT PERCOLATION RATE -�'3S. 77/A! .TNd. MIN/INCH -- — LEACHING AREA PER PERCOLATION RATE'.-'5' . SO.FT. Alp .WATER ENCOUNTERED NUMBER OF LEACHING PITS APPROVED . .. . . . . . . . . . . BOARD OF HEALTH Q`.SjV V4-0M AZG S/C�dS:_ /.5 AIS oT St,/&• P&)e P/T 'TliOVA:s B:KELLEY CO. DATE w ENGINEERS—SURVEYOR AGENT OR INSPECTOR 346 LONG POND DRIVE %� UTH YARMOUTH,MAS . Lt31 O\ N OF MASS dr�;] +►y ? n••e 02664 p THOMA EDINA g IN�o K�I.J��; 42e0 3>0 l V1_:_ 23100 6� /�� O STE C-4t,? - TZ670z711 7;Y e S7' ✓ ��;�F`G 3=•:4'' NAt�a6 LPETITIONER : WET s a27- wo LO-CAt+ T0N /"1 SEWAGE PERMIT NO. f / d VILLAGE INSTA LLER'S NAME i ADDRESS 1 9 UILDE R OR OWNER DA T E P ERMIT ' ISSU E D DATE COMPLIANCE ISSUED -7 , • � w ®'' ,� a `� 1 .� LO-CATION SEWAGE PERMIT NO. VILLAGE .Av 16 r.r1 h1Zff I N S T A LLER'S NAME IL - ADDRESS 3 U I L D E R OR OWNER h-;pLZ1-y ' r DATE PERMIT ISSUED E 0MPLIANCE ISSUED DAT C p� �D 1 y3 J, �