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HomeMy WebLinkAbout0274 NOTTINGHAM DRIVE - Health 274 Nottingham Drive Centerville A= 171-039 IN UPC 12543 No .2R. fi`bsr{o � HASTINGS,MN TOWN OF BARNSTABLE LOCATION o77y Vywr -?!% 4Al * SEWAGE #,!)?,O// VILLAGE�G�iVTe'�12�/i I L� ASSESSOR'S MAP & LOT r INSTALLER'S NAME&PHONE NO.C." WSV- 6 SEPTIC TANK CAPACITY MAO 6-11&o LEACHING FACILrrY: (type #0 J� A&V (size) NO. OF BEDROOMS BUILDER O�R �/GJ�If�iit! (��� �Q D,` ,.0 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � r t L� q AB �6� No. Fee ` THE CO�Gi~O4WEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYitation for bisposal Opstem Construttion Vermit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7!!M Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �C � Installer's Name, ddress,and Tel No. Designer's Name,Address,and Tel.No. rf �fp/'�P( y���02ry/�'i' �P ��. 'Z` 1 trio .O�t 9�GsV Type of Building: Dwelling No.of Bedrooms -3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)334> gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 0tX0 (5;fAY_1&y Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 En ronmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar a h. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ZO I 1 ` 2 60 Date Issued oo 70 yea �t..' - Y�..+►�. ..- ,�+-�"...+...t.. ` _...� Q,d am!l No. Fee l` Entered in computer: THE CO ` IVIOiV�IVEALTH OF MA'SSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,'MASSACHUSETTS 01pplitation for OispoBal 6pBtem Construction VErinit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.a rN ,/L!p i,) 14M D+7• Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer'srame, ddress,and Tel.No. Designer's Name,Address,and Tel.No. POp .�j - 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)3� gpd Design flow provided ,`S 'j ,� gpd Plan Date Number of sheets Revision Date Title p Size of Septic Tank la-V •-�VtAV Type of S.A.S. �r�fJ 1�iQ� C..146A1s 4S Description of Soil Nature of Repairs or Alterations(Answer when applicable) y A�y, TG t 3 Date last inspected: Agreement: r The undersigned agrees-'to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar a h. Signed Date C) /� 4 Application Approved by Date 1 Application Disapproved by Date for the following reasons Permit No. 20 11 - 2 G 9 Date Issued a ZO t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance ' THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(lam Upgraded( ) Abanddned( )by at%�'7� V,06%ZeA7 A7 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.VD ' Z I Z68 dated (� O t 1 Installer ( 4,e 0,,X14[ (17 s T, Designer_d y,o A45eAJ #bedrooms 2 Approved design flow �$?30 and The issuance of this permit hall t be construed as a guarantee that the systems will ruin�trbjvasy�Jbsigned.. ..Date I ", � Inspectors _. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Oisposaf .6pstent Construction 'ermit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at &IN and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe it. Datej Approved by , s Town of Barnstable �VK r Regulatory Services ti Thomas F. Geiler,Director MASS. Public Health Division 9�Ar . INk � Thomas McKean Director FO ty�pl 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax:: 508-790-6304 Date: ZLIL Sewage PermitVjjd-- Assessor's Map/Parcel/ !— Installer&Designer Certification Form Designer: DI V40o� Installer: 6 2L>1*1 >l �. Address: ��y'y 6 !J6�^(I� ( Address: X"117FT On Zljl � �1w�Q'C� (fVLdS was issued a permit to install a (date) (installer) septic system at 4 m —j�a. based on a design drawn by (address) O. dated (designer) . a 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. Stripout (if required) was inspected and t�e soils were found satisfactory. 0���1p1'TTO�� `Tt-�. LforC A LvH► � EN tom£ �` l � 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 R '-t.ions. Plan revision or cert*fied as-built by designer to follow. Stripout (if rP- cted and the soils e found satisfactory. �P��N pF Miss o DAVID y A B. nstaller' gnature) o MASON 9 No.1066 �j J /sT A (De er's Signature) PLEASE RETURN TO BARNSTABLE PUBL._ OF COMPLIANCE WILL NOT BE ISSUED UN i iL tsu i n i tuN r'URM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice foams\designercertification form.doc l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments f a° 274 Nottingham Dr. G•,M Property Address Sidney& Ruth Shapiro- Owner Owner's Name b information is ` required for Centerville Ma. 02632 5/11/2011 1 every page. City/Town State Zip Code Date of Inspection 'E 4 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your cursor-do not Robert Paolini a Name of Inspector use the return k key. Capewide Enterprises,LLC. Company Name Q P.O.Box 763 `i Company Address Centerville Ma. 02632 reran City/Town State Zip Code (508)428-4028 S 14454 Telephone Number License Number c. x B. Certification a; 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: a q. ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 4 U-1 .. rJ 5/11/2011 In pector's tignbli.Xle Date Cn, Tile system inspector shall submit a copy of this inspection report to the Approving Authority(Board e—n C;! ofjHealth or DEP) within 30 days of completing this inspection. If the system is a shared system or LL— has'adesign 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 ard78opies 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. 511 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sew4Disposstem• age 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is Centerville Ma. 02632 5/11/2011 required for every 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 e A) System Passes: i ❑ 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 f indicated below. Comments: r k. B) System Conditionally Passes: , ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. _ Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ass inspection if with approval of the Board of Health): Y P p ( pp ) ❑ 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: a ❑ 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 rk t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 c a Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments li N 274 Nottingham Dr. 3 Property Address F Sidney& Ruth Shapiro Owner Owner's Name #� information is required for Centerville Ma. 02632 5/11/2011 a 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. f ❑ 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 t more from a private water supply well". Method used to determine distance: 1r *'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 1/2 day flow t5ins•11/10 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 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every page. CitylTown 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 11 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. S' t t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 w Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every page. Cityf 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? t ❑ ® 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? Z ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, . dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 20 ,000 2010::17 ,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CM 15.203): Gallons per day(gpd) L Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes .[E No x Industrial waste holding tank present? ❑ Yes E] No Non-sanitary waste discharged to the Title 5 system? ❑ Yes Lij No i a Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 274 Nottingham Dr. iG^M Property Address # Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): # a i t General Information w Pumping Records: k Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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•11/10 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 �^M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1411 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Orangeburg Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 811 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i A Y' If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 0 �t ;f t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 R} Commonwealth of Massachusetts W Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a 274 Nottingham Dr. Property Address . Sidney& Ruth Shapiro Owner Owner's Name y information is required for Centerville Ma. 02632 5/11/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 3 Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 0 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? Measured t Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. t 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �^M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every 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.): F. i Y "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑:,No 91 4 1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every 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 No D-Box 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.): 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 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 ^M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Sandy soil.Leaching pit was dry at time of inspection.Stain line observed up to invert.Large tree on top of leaching pit.Observed roots in leaching pit. •r x Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert a rt f Depth of solids layer , Depth of scum layer .'s Dimensions of cesspool t Materials of construction ILI Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page`1.3 of 17 }} 5' Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 274 Nottingham Dr. Property Address t Sidney& Ruth Shapiro e Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every 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.): t T 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.): r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 I ' Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® ® Zoom Out jIn 4. e h I •tea k":�� E O u 1 . . Fe.t' Set Scale 1" 20 `Aerial Photos I MAP DISCLAIMER (:nnvrinhi 9Mr._9!NO T--M P.—O.W. NA6 All rinhTc roconi - http://66.203.95.236/arcims/appge.oapp/map.aspx?propertylD=171039&m.apparback= 3/18/2011 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments GSM 274 Nottingham Dr. Property Address Sidney&Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 274 Nottingham Dr. Property Address Sidney& Ruth Shapiro Owner Owner's Name information is required for Centerville Ma. 02632 5/11/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t f f, t A i y. { f 4 i t 11 I jzF} R G: 4� f t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i i. o+� Town of Barnstable P# C �� Department of Regulatory Services ."a►r�,u3� i Public Health Division Date 200 Main Street,Hyannis MA 02601 00 � Date Scheduled _ Time_ Fee Pd. DD .�� Soil Suitability Ass sment for Se Disposal Performed 1`� Witnessed By: _ LOCATION& GENERAL INFORMATION Location Address 7V 104f6 i 17q#4�t �R�' Owner's Namec5'41, AIV '• '&O;Jep ft ® Address �u� i i►�ly'9n1 DLi 1C Assessor's Map/Parcel: ` Engineer's Name 4Yi 0 A lqS111 NEW CONSTRUCTION REPAIR t� Telephone# :SAS' ,1 -7 Land Use Slopes(96) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I I _ -n .. co Parent material(geologic) Depth to Bedrock. J Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face `s Estimated Seasonal High Groundwater 30 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: In. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor, q� Adj.Groundwater Level, I PERCOLATION TESL' Date Time.w._, Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time m Time(9"-60t) End Pre-soak t Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. i t or:y,2 Gravel) /, G lv 26 6 Ov DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistencv.%Oravell DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consistency, Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes 1/ Within 500 year boundary No= es Within 100 year flood boundary No., Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u rial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of n turally occurring pervi us material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed y me consistent with . the required training,experti nd ex en e d cribed in 310 CMR 15.017. Signature ate 5 Zb! Q:4SBPTIOPERCFORM.DOC I ASSESSORS MAP : # f _ NOTES: TEST HOLE LOGS PARCEL: -Z/ 39 FLOOD ZONE: SO I L EVALUATOR � VI1,� , k 1) The installation shall comply with Title V and Town of Barnstable Board of a _ _ _ _ __ � WITNESS : I T I Health Regulations. REFERENCE: � / C� _z ���` _- --_---___ ) verify , inverts and septic `� _ � �7 DATE: ! ' 1 � 2 The installer shall ven the location of utilities sewer , jUL1e, u / PERCOLATION RATE, - components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first f--,--.-- 71--- two feet out of the d-box to the leaching shall be level. / TH- I TH'2 4) This plan is not to be utilized for property line determination nor any other purpose,other than the proposed system installation. l0 Q l0'� Zv 5) All septic components must meet Title V specifications. 1.11 A �l 5 6) Parking shall not be constructed over H10 septic components. j 10 V ;1 �� 8) The The property is bounded by property corners and property lines. LOCATION MAP7 4 ) property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt i - of payment for the plan and installation based on the plan shall be deemed y � approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material Q-T per Title V abandonment procedures. Those within the proposed SAS shall 60 be removed along with contaminated soil and replaced with clean sand per Title V specs. 10 System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. _ 12)The installer is to take caution in excavation around the gas line if such — — / Z 4, , 4,-7 - - — - exists. BEDROOMS AT 110i PAL/DAY/BEDROOM GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer EXI-74,�-) dines exiting the dwelling prior to the installation. P'T C AHK 14)This plan is representative only that a system can fit on a roe meeting -- Title V requirements. property g (� �IGAL/DAY x 2 DAYS - U2a GAL �,,�.�y USE L`(� GALLON SEPTIC TANK ��'l Ih((�._ _...��W'_._�.._�Lf ---- w�1, ---------- SOIL ABSORPTION SYSTEM LCOP Q tTDHC, OF 41 UV-1 IT& 4 3 2- � ►� �� DAYtW `o - �'� l( �a 2, 600Put�S I,Ilo L� 'x 5, ,t ', = t la ,F �. `� MASON M _ J� `�(! �� No.106 6� �y i I .,. SEPT I C SYSTEM SECTION ` N ( p � - -�,� � 16 ��) �s1,33 z'°. �"�Stow e�2 Ft,-� Wee ' 01 5 0 0 o q 0 q D 9 0 GAL , w ° q o 0 0 % a 5 ,QO —_ SEPTIC T� \j ..%./cam"_oy_"TZ%�%T.�✓LG©i�V. . - ---, VE SITE AND SEWAGE PLA � . ._. PREPARED FOR : C_ <fo l8TI M ' P SCALE, ` �Z W DAV I D B . MASONIRS DATE: 8 5 2011 o DBC ENVIRONMENTAL DESIGNS g EAST SANDWICH . MA W DATE HEALTH AGENT ( 508 ) 833- 2 177 3 W Z i t i