HomeMy WebLinkAbout0273 NOTTINGHAM DRIVE - Health 273 Nottingham Drive
Centerville F/R
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UPC 12543
No.5_3LLOR
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address IY
John Shea
Owner Owner's Name --
41
information is A'
required for every Centerville MA 02632 08/12/2017
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 A. General Information
filling out forms �5.a Qn
on the computer, // •-
use only the tab 1. Inspector:
key to move your
cursor-do not A.Riker
use the return Name of Inspector
key.
R.L.C.
Company Name
PO Box 726
Company Address
/ems South Yarmouth MA 02664
City/Town State Zip Code
508-776-6460 S14590
Telephone Number License Number
B. Certification -
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
08/17/2017
Ins ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 ofI17
4 0�e Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
Inspction of septic tank distributionj box and area of SAS was onserved to be on operating condition
with no failures observed.
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 exfltration 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 Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. CityfTown 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is Centerville MA 02632 08/12/2017
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption 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
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•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
°M 273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well:
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
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): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
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
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2016=1000gallon
g ( y g (gpd))" 2017=7000galIons
Detail"
2015=19000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City(rown 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: homeowner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: n/a
gallons
How was quantity pumped determined?
Reason for pumping: Annual maintence recommended
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
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:
Septic tank age unknown distribution box and leach chambers installed in 05/18/2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2' PVC construction
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town water from street
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
dry with no evidence of leaks observed
Septic Tank(locate on site plan):
Depth below grade: 1.2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gallon precast concrete tank with PVC inlet Ty and concrete baffle on outlet
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5x5x8'6"
Sludge depth:
14"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle 8"/baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? 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 was observed to be in working condition with some roots removed around inlet with water level
at outlet invert.
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
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 equal to single outlet
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.):
Riser was installed at time of inspection by homeowner. No obvious concerns observed.
Pump Chamber(locate on site plan):
Frumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
1
* 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4xlnfiltrators with
stone
❑ 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.):
Soils above SAS were dry and free of effluent stains or odor
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
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
}4 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
pz
't
f�
r
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
C
cll
^/
I
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
i ® Surface water
® Check cellar
® Shallow wells
Y Estimated depth to high ground water: NO GW observed > 12'
feet
+ Please indicate all methods used to determine the high ground water elevation:
F ❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
f
i ® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Permit on file with COC
`3 ❑ Checked with local excavators, installers- (attach documentation)
r
❑ Accessed USGS database- explain:
F
You must describe how you established the high ground water elevation:
I Permit on file and plan with testhole data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Nottingham Drive
Property Address
John Shea
Owner Owner's Name
information is required for every Centerville MA 02632 08/12/2017
page. CityF 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
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t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
AsBuilt Page 1 of 2
TOWN OF BARNSTABLE
LOCATION 273�aTT� //A ti /1 /y� J SEWAGE#Q a9y oZ.�f`1
VILLAGE t� .v?C 2 d� ��� ASSESSOR'S MAP&LOT 1?i o
INSTALLER'S NAME&PHONE NOG9a1,04—A r Cj' S:d d '> 2 1 3 6 3
SEPTIC TANK CAPACITY
LEACHING FACILnY:(type) Y. .Z
NO.OFBEDROOMS 3
BUILDER OR OWNER 136Y
PERMITDATE: /VO4 COMPLIANCE DATE: 0
Separation Distance Between the:
f 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�
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7
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C-)<,sr t3 c / 7 ,
10005T 3 �L9
p�b� �f'ffiCAP
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I N Fi' TR 9 y0
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=171048&seq=1 1/24/2017
�44
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for M.5pozal *p5tem Cone;truction Vermtt
Application for a Permit to Construct( )Repair Grade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot.No Lv1 er's Name,Adre aTel.No
Assessor's Map/Parcel
l d��
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
!L e^( ,,, V v. GL R e.,- may 2
.S`D
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 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
n
Nature of Repairs or Alterations(Answer when applicable)
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 Certifi-
cate of Compliance has been i d -is Bo of Health.
Si Date S -
Application Approved by Date
Application Disapproved for the following reasons -
Permit No. i Date Issued
a
No. - Tee
THE COMMONWEALTH OF MASSACHUSETTS Entered iri computer:
f j Yes
PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLES MASSACHUSETTS
r 2pplication for Miopooaf *p5tem Construction Permit
Application for a Permit to Construct( )Repair(el Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lo No?.,� V Owner's ame,Addrye and Tel.No11
Assessor's Map/Parce
Installer's Name,Address,and Tel.No. _ Designer's Name,Address and Tel.No.
5`097� � �� 36�
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 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
Nature of Repairs or Alterations(Answer when applicable)
a�
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 is a d y this B and of Health.
Sippe r /.t .' w ),— Date
' Application Approved by j, l i �/!i/!� ��7I Gvi ! Date
Application Disapproved for the following reasons /
A4, .,>f 1
Permit No. Date Issued
------ ----------- - ---
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliauce
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded( )
Abandoned( )by A G N
at 3 / T 1 hasjb1,e�en constructed in 'cordance
with the provisions of Title 5 and the or Disposal System Construction Permit No. 1 —'"`l /dated S !6 V
Installer A A,_-
Designer_�1 VIZ 4
The issuance of thi pertiit qall not be construed as a guarantee that the s tem ill f tion as Zdi,ned.
Date I F/b . Inspector
�9
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Miopool 6potem Con5tructton Permit
Permission is hereby granted to Co struct k ) epair((- Upgrade,( )Ab�ndo
System located at .�� ;7A=S'.,
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.
Provided:Constructi n must bb-e�completed within three years of the date of thi //Srm tt'.
Date:_ ._ � �( / Approved by
1
I � ,b 12r6
I~u 1 1
�V
9 .
1000
TOWN OF BARNSTABLE
LOCATION Z72/Y0'771'`"g�A"' ,1�ia, o V F SEWAGE#
VILLAGE a I
� ASSESSOR'S MAP &LOT t 74 41
INSTALLER'S NAME&PHONE No
SEPTIC TANK CAPACITY
LEACHING FACII iTY: (type) ��� �'',L•✓�/T size)NO.OF BEDROOMS-2—
BUILDER OR OWNER
PERMIT DATE: .
/0 COMPLIANCE DATE:
Separation Distance Between the:
Feet
Maximum Adjusted Groun&xater Table to the Bottom of Leaching Facility
Private Water Supply We11 and Leaching Facility (If any wells exist
Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist
Feet
within 300 feet of leaching facility)
Furnished by
L� a3 r
10005Ese—
JI
D Y zr
Town of Barnstable
IWHE Regulatory Services
Thomas F.Geiler,Director
• BARNSrA MX •
Public Health Division
A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: -(
Designer: DAt2llZe� M. /gC-yeg Installer:
Address: . -F 0- -BOX q Address: G>c l y
• SINraw 16,44 S37
v
On was issued a permit to install a
(date) (installer)
septic system at '7-- 3 0 /N ,4 I V& based on a design drawn by
(address)
L)A-R—X-,eAJ M /-t dated Mam
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
f /
rY` I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State &Local Regulations. Plan revision or
certified as-built by designer to follow.
taller's Signature) MEYER =
r'1 #1140
1FO
(Designer's Signature) (Affix Designer's Stamp Here)
v
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION: CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
I_
TOWN OF BAMSTABLE �e
LOCATIONf�A 1 1�,F SEWAGE#,2
VILLAGE Cep T C R a., �/� ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NOGQae,4e&"a'-"7` S d 8 `7 Z 3.0 a
SEPTIC TANK CAPACITY /6 00Y ' s°? '
LEACHING FACILITY: (type) 9*!L,y'��✓/S' /r-Q/4,-a (size) t3 Ul /e ANO.OF BEDROOMS 3
BUILDER OR OWNER 136Y �'✓� �'
PERMIT DATE: COMPLIANCE DATE: -5- 0
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
P02 -7 �x ,f,
P,D ® 100037,
BE cr
0 5 ,�
CAP
t Al f i' 7`D
COMMONWEALTH OF MASSACHUSETTS T10"'
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECE ED
APR 2 7 2004
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION TORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A 7
CERTIFICATION i\AAP
FARM' O
Property Address: 273 Nottingham Drive 0
Centerville, MA 02632 LOB
Owner's Name: Bob Giannetti
Owner's Address:
Date of Inspection: April 20, 2004 FAILED INSPECTION
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Need urther Evaluation by the Local Approving Authority
✓ Fails
Inspector's Signature: Date: April22, 2004
The system inspector shall sub ' a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
' Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
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.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box 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:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
' Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than % day flow
_ ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ 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 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.]
Yes (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 System:
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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 273 Nottingham Drive
Centerville, AM
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
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:
Yes No '
✓ _ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
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: 1
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): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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: Never pumped-per 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
✓ 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:
Installed 10122185-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 14"
Material of construction: ✓ 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 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement baffles were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
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 8 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
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 alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present.
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 I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 - 6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool, number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
The leach pit had S.S'of liquid on the bottom. The scum line was up to the pipe. There appeared to be signs of failure. The
bottom to grade was 8. The cover was 2'below grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
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.
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10
t
Page 1 1 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Nottingham Drive
Centerville, MA
Owner: Bob Giannetti
Date of Inspection: April 20, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- 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: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and water contours map, the maps were showing approximately 25'+/-to ground water
at this site.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
J
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street Boston Ma. 02108 .Jolui Grad
' D.E.R.—Titre V'Septic Inspector
P.U. Box 211p9x
Teaticket, MA 02536
(508.)564-6813�
WILLIAM F.WELD ,
GovernorV i"r
w p
ARGEO PAUL CELLUCCI �; Ark 2 ,
Lt.Governor1998 en
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM` TOWNOf
PART A Hp HD pS SLE
CERTIFICATION
.n
6' �
Property Address: 273 Nottingham Dr.Centerville �1 Address of Owner: 8 ly !V
Date of Inspection: 3/12/98 (If different)
Name of Inspector: John Graci Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and 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:
X Passes This Inepection le based on criteria donned In Title V
COndltl0 II SSeS code 310 CMR 16.303.My findings are of how the system is
y performing at the time of the inspection.My inspection does
_ Needs rth Evaluation By the Local Approving Authority not imply any warranty or guarantee of the longevity of the
Fails septic system and any of Its components useful life.
Inspector's Signature: f/ Date: 311e198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoThpltance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised OVUM)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 273 Nottingham Dr.Centerville
Owner: Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
Date of Inspection:3112JOB
_ Sew.ane backup or,hreakout.or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if .
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
s 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other �
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in 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
cesspool.
SAS is in hydraulic failure.
(revised 0427187)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 273 Nottingham or.Centerville
Owner: Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
Date of Inspection:3112199
D]SYSTEM FAILS(continued)
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).
Numbers 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 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. 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.
•b
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
-. The following criteria apply to large systems in addition to the criteria:
a The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 273 Nottingham Dr.Centerville
Owner: Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
Date of Inspection:3112198
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
—x—. — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x 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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)]
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 273 Nottingham Dr.Centerville
Owner: Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
Date of Inspection:3112l98
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3m g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy:January
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: rda
Z. OTHER:(Describe) rda
-Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nla
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source Information:
1970
Sewage odors detected when arriving at the site: (yes or no) No
(revlaed 0412T197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Nottingham Dr.Centerville
Owner: Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
Date of Inspection:3112199
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 1'
Material of construction:x concreate_metal_FRP_Polyethylene—other(explain)
If tank is metal, list age rda , Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L9+a°°H67"w4.10"
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:0
How dimensions were determined: measured
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and all components are structurally Bound and Nnctloning properly.Recommend pumping every two years.
GREASE TRAP:
(locate on site plan)
'Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: ria
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:ria
Date of last pumping;.
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1°s°°
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line:t—
Diameter: 4"
r,dimments: (conditions of joints,venting,evidence of leakage,etc.)
(reylsed 04127)97)
o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Nottingham Dr.Centerville
Owner: Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
Date of Inspection:3112fg8
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: n!e
Capacity: nra gallons
Design flow: nla gallons/day
Alarm level:_nta Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Ma
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: liquid level with boltomofpipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
D-Box Is structurally Bound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
nfa
(revieed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add re s s: 273 Nottingham Dr.Centerville
Owner: Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
Date of Inspection:3112198
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: one IpW gallon leach pit
leaching chambers,number:nla
leaching galleries, number: rda
leaching trenches, number,length: nfa
leaching fields,number,dimensions:rda
overflow cesspool,number:nla
Alternate system: nra Name of Technology:_we
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Leach pit and all components are structurally sound and functioning properly.Leach pit Is currently empty.Leach pit has had 4'of water In IL
CESSPOOLS:
" (locate on site plan)
'Number and configuration: n1a
Depth-top of liquid to inlet invert: nla
Depth of solids layer: nfa
Depth of scum layer: nfa
Dimensions of cesspool: Na
Materials of construction: rda
Indication of groundwater: rda
y inflow(cesspool must be pumped as part of inspection)
nfa
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
we
PRIVY:
(locate on site plan)
Materials of construction: rda Dimensions: rva
Depth of solids: rya
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Ma
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
273 Nottingham Dr.Centerville
Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
3112198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
IR
MaiA�
C 0
9
aG
Y
GA f�
Pays ! o! 30
(revised WNW)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
273 Nottingham Dr.Centerville
Estate of Anne Knowlton:8 Volunteer Rd.Hingham 02043
3112199
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
F
t
(revlsed04r27197) page 10 of 10
-- sr
No._.................. Fizz....i...................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tow-m...............OF....8A.A-1VA1,R.j/.e,..... ...
MIS 1�1- (A% Appliratimi for BWpofial 19orku Cnonstrurttuat Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
LocatiojAddress or Lot No.
i
rs G.....--•...................... ........ �.�.���1....... A�.Q--....................,
......, .rd.. .............................
caner ress
W
Installer / Address
Type of Building Size Lot...b..ffY.__.._..Sq. feet
Dwelling—No. of Bedrooms.....................3...................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _..�,�[i6P1 W#__ft.No. of person............................. Showers ( ) — Cafeteria ( )
d Other fixtures .
W Design Flow............................................gallons per person per day. Total daily flow__-----a..........._........_.......gallons.
WSeptic Tank—Liquid capacity./M.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Widt .................. Total Length.................... Total leaching area....................sq. ft.
e Pit No......_Seepage ...... Diameter �'
p g IIc
e'Depth below inlet.................... Total leaching area_._�Cz_a`l-....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........................
1:4 --------------------------------------------
•-•••-••--••-••••.........
•-------------
.--------
--.----
---------------------------------
...--------•--•---
UO Description of Soil------. _9kA.g.Q--------------------••-•------------------------------------------------------------•----------•------
••-------•---••••-••••----••----•--•••-•-...---•-•---•-•---•---•-•----•------•----•-•--------------------•-••-••••--•-••••------••-••----••••-•---•-•---•---••.•---
OT' •••--•-••-•----••-----------------------•-•-•----••-•••-•--•--••---•---•-•---•-----•------••••---•---•--•---•---•----•--•--------------•-•......•-•----•--••------.....................................
V Nature of Repairs or Alterations—Answer when applicable...........................................................................1._._......_......._.
----------------- ----------------••--------------------------------•-----------------••--•-•-.-•--•--•-•-•••--------••-•----------•-••----•--------••---•-••••------•--••------•---•--•-.............--
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 bee slued by th oa o h th.
Si e
Date
Application Approved By......... C..... . . . ... ..--------------•------.....-- -- t 2� 7 2.
Application Disapproved for the followingreasons:-_._.._.'�...............•-•---•-----....._......._....... ate
••-•---••--•---------••--•----------•----•-------------------------------•-----••---....-------------•---•--------•••----•--•-••---••--•-••-•----•••••••---•-•---•••------•----•••••---.....•-•--.••----
Permit No......................................................... Issued....... �--------7 2_
- .......Date...._.
' Date
No.... F$�.. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOA OF HEALTH
.........::.jt s .. ...............OF.....c3A Aajs
Appliraffun for Disposal Works Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
LocationeAddress or Lot No.
[.......� .c.............................. ... f}. ' ! . . e x�. :: ......,......................................
Owner °^, Tess
W' ...s,�G1 r9!.S"o......... 5�€.J.t _✓
W +.' --- q
Installer Address
UType of Building Size Lot...J`?�4�*'��........5 feet
�-, Dwelling-No. of Bedrooms..................... ..................Expansion Attic ( ) Garbage Grinder ( ),
aOther
—Type of Building ...blo .w_0.f No. of persons......... ................ Showers ( ) — Cafeteria ( )
dOther fixtures ----•-•--•-••-------•-•---•-••----•--•..................--•---------•-----------•---....................................................------...._...
W Design Flow............................................gallons per person per day. Total daily flow....... .rn.................____.._.__gallons.
WSeptic Tank—Liquid capacity./.!. 1gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x Seepage Pit No..................... Diameter............ ' 5De th below inlet.................... Total leaching area -....s . ft.
3:': dr. P g q
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........................
Ix ---•-----•-•••••••-••••---••-•••-----•--...---•-•-----•-••----••-•-•----•---•••-•-•---------•.....••.........................................................
O Description of Soil........ h,_t " �?E c•J................
V ................•----••---•---•••--••••-•---•............11-............_._.........-•--------------••••••--•-••••---•••••••---•-•-•••-•-••-•••-•-----••--•••----•--•-•-•-•--..._........------............
W
V Nature of Repairs or Alterations —Answer when applicable................................................................................................
E.
...... .................::...............................................................•-••--................------•........._.._.•-----........................._.
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 bee issued by th oar- ofr)heath.
Sied.;. ,)n- ; •.
g
01 Date
Application Approved B
PP PP Y ..............................
ate
ec
Application Disapproved for the f ollou inn reasons----------------•----•-------------------------•----••--...------••-----••••-•-•----...__........--------.....--
•------•................•---•-----•--•-------••--•-•---••---................................._...••-------•--- -•--•----•••-•-••------••......-•----------------•--.....•------------•---•-----•......••
Date
Permit No.......................................................... Issued-----.. ma c. ' S -•.........
Data
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... ..... ............. ..............................................
Trrfif iratr of Toutplittttrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-------------- �6f" ...._..� • ✓ f�.Y-------------------•------------ ---
Installer
u'lJ� /Its .1 19 An _"�_f_'"1 _C,..._.
has been installed in accor nce with the provisions of Article XI of The State Sanitary Code descr'bed in the
application for Disposal Works Construction Permit No.......................... i'�_ dated_.... t�. ___ � :..._.. _._....
TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL FU CTION ATISFACTORY.4 1
DATE. .f.........................................'° ....... Inspector....... -.�: ......... _d :.. .....:....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/..`....!::'....................O F..........419 .. �
` �` '
No..........:.............. FEE........................
�i����ttl f�rk� C�.�rt��rixr�iun �lermif -
Permission is hereby ........ 1 ° +° ? ......................................................................... . .
to Construct ( ) or Repair '.(J. an Individual Sewage Disposal Systern
at No..:._. 0 T fit.._.... .... '{ rTxr6a_l� �.............. '' t" _. 1 .
......:--•--...... ....... ........:.
Street
as shown on the application for Disposal Works Const;ruction Permit No..................... Dated_._` ....................
�. , ., `�---. --------
- Board f Hcalth
DATE.....=.............................................
......................
...............
FORM 1255 HOBBS & WARREN. INC::`-PUBLISHERS
/° •` ` R � "` ' ASSESSORS MAP : 11I TEST HOLE LOGS NOTES:
PARCEL : O4q j 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
SOIL EVALUATOR : V• Me4e k �,Sl C e, THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF
a ' FLOOD ZONE : I��a►3 R�t�-�� r� ' (1vft�i BOARD OF HEALTH REGULATIONS.
WITNESS : �I,Q'!' E� V_l pz
l �° THI REFERENCE: lb�' ��375 DATE: IKIL
lob THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
1 44 { �i2� PERCOLATION RATE: G 2r�i1� (�J(,N SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
_ (LkSS .t 'COIL, _ d►-? p INSTALLATION.
SEPTIC SYST�Ft-1!1 it TH- I �,[,.:0•S5_ TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
t _ Q I (J R ��M ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE
A_
s wMp ( 2� S ' -` Cjn SkAl lvyp / DETERMINATION.
4) ALL PIPING TO BE 4" SCHEDULE 40 1/8 "/ FOOT. (UNLESS I,UA„^y SPECIFIED OTHERWISE)
A � 3 : 5� � !3 _ /� s"o
LOCATION MA P(,N' ,5) _ 1 i to 2Y Iv►.Irnl v�Nl 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
/k 'q" 70 GARBAGE DISPOSAL.
58
9 � �
5"o R 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
GI l C tj1,SSg MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
2,5y VA A BASE OF 6"OF CRUSHED STONE.
7.) isTrNc� l / piT19 PJE�._PvM�><o/
120 52-55 -
r �f 0 G� U�,Sc�v�� �rwr►L .. _
Ioo,o Pam?
11' SEPT I C SYSTEM DES I G N is ' or
' '+ k>r •1 FLOW ESTIMATE
3 BEDROOMS AT I GAL/DAY/BEDROOM - 336 GAL/DAY
SEPTIC TANK -
�)30 GAL/DAY x 2 DAYS - U GAL
USE 1,.000 GALLON SEPTIC TANK - ��t S• n►4 - y�C��E Wl !� SOu Cwd S pr r
�✓t-w Ic.- I F ��1 Lt:o� 1�A✓vtq-c�F�J �,�
SOIL ABSORPTION SYSTEM vNbEr�S t2�p
�i t(-u CA-POK tom-, I Nr-I LT�raI?- UN IT-S 'W
-2-5 STONE ON EN95 1:� 3-Sg'STUYIECW S19,Fc nv'Lx Io'wx s D)
O (BEd lo)L x2 0. IIs, �o>< � Y -
� SIDE AREA �JJ 2f• C
� BOTTOM AREA: 30 x 10 O x . 7 y '
� CA 222
pr�
SEPTIC SYSTEM SECTION �33°� ' `� r•�
10 F
fl I rr,/xx ' lD o »r S� Yat1G q rMnti 4" „3p daf/ln.� t
G<�rJ�� � ID �hS''•gl) I� � �„ W/►h Gy Of- �jnlS�
le �v.87 J{apt
7r �Zv L Kn s �e -
GAL / �c
-BOX 60.zoov0 C4- Q K ISfI " SEPTIC TANK rGC, Y ' v04
1 I >✓ E'L't E?Cr s7"/� ` 3UJ S EL-'. 57.b0 /
S
FtGF, LIV.r s, .30 5 as9 ) -T ���
l�•O .�I �o'To�, a� C-ST-toc--� EL; JCSs�• SS
J �
'`--2 _3i$" �blt SITE AND SEWAGE PLAN
/\,l0 7- /A.)4 DF,l V F wlsof svoe
lo' LOCATION : 2`7 3 1r) ha,v, Dlekoe
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�P oFC�R-.S G'� ,-. �o� N yG� Zit W A-ShE� 571,IVE
i �n.
ro3,os EYER e I PREPARED FOR : A C6AJS79-!/010A)
A55 v Mho No. 1140
���rsTE�� ���� �r 34� �3.► SCALE
b S
a i1 N �NITAR\P IbI DARREN M. MEYER, R.S. DATE: 6 U
43 VINE STREET
s �(,�kr► ot~ (,A +�, M . k40N4Hpw DUXBURY, MA 02332
cekTlrlev S �3t�c,T Mu
DATE HEALTH AGENT 781 `585-0293 /9 y
Z. �� N� 3� 11�/ y