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HomeMy WebLinkAbout0283 NOTTINGHAM DRIVE - Health 283 NOTTINGHAM DRIVE, CENTERVILLE A- No. 42101/3®RA 0�b�PGR 10°l0 , o o TOWN OF BARNSTABLE LOCATION p�0� a YAM ���'�-� SEWAGE#t.--ab— /j S VILLAGE G�i/�"Cris (7 SESSOR'S P&PARCEL 1 '7 I �� INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS OWNER ` , e#.,,LU PERMIT DATE: t - "'-26tk 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 AL eo.t ST 6 6� Y No. _�^ � /✓✓ i Fee /lJ� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for Mioozal 6p.5tem Cowarwtfon permit Application for a Permit to Construct( ) Repair( ) Upgrade 9A Abandon( ) ❑ Complete System Individual Components Location Address or Lot No.f /� �� f m y i Owne 's am Address and Tel.N 171 - �/� /' 0 D q6 p7 i�ShehJ Assessor's Map/parcel OL —1 Install�NAddress,' and Tel.No. 609-l7 9-19q f D signer's Name,Address and Tel.No. 6�53(� Type of Building: Dwelling No.of Bedrooms l Lot Size — sq.ft. Garbage Grinder ( ) Other Type of Building i No.of Persons Showers( ) Cafeteria( ) Other Fixtures a Design Flow(mi//n��.,,re��qui��red) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /�Oi Type of S.A.S. Y J� 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by th Boar of Health. Sig ed Date Application Approved by Date L - Application Disapproved by: Date for the following reasons Permit No. S C)p CP Date Issued _ 1 No.. (� 15 ` �� �� �, Fee 166 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 3pplic tion for �Bigo!gaY 6p6tem Cow5truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(/' Abandon( ) ❑Complete System Individual Components Location Address �r of No. �(} ( m f' Owner's Name.Address, d Tel.No• Assessor's Map/Parcel 1-7/ -()qq I�DhD�GS f i C�SO?Ph�D Installer's Name,Address,and Tel.No. 50 77 d-18' f Designer's Name,Address and Tel.No. Type of Building: r Dwelling No.of Bedrooms Lot Size 5, ttb sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min requir d) gpd Design flow provided gP d / Plan Date Number of sheets Revision Date Title Size of Septic Tank r ►5 kn 6 /(Zo zl� Type of S.A.S. Description of Soil V U ! Nature of Repairs or Alterations(Answer when appllicable)/ Date last inspected: Agreement: _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig led Date Api !ji Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. CMG& 5 Date Issued ———————————————————————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (�) Abandoned( )by _ at c�i� o -inchct Q, r Le v/ I has been constructed in accordance j�7 with the provisionssJ of Title 5 and the for Disposal System Construction Permit No. c� / dated , G Installer W /��� Designer #bedrooms Approved design flow The issuance of this permit shall not be construed as a ar ntee that the syste will fu tion as esi ned. Date ! ^ ��� Inspector �,"__C— - - -------------------------------------------- No. —/5 1 Fee /00 c THE COMMONWEALTH. OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS �MI!9po!5al ,p!5tem Con.5trUCtion Permit Permission is hereby granted to Construct ( II)- Repair ( ) Upgrade ( )_ Abandon ( ) System located at _9 8-3 � #z k6c/72 1!V e .,>° t. U 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 conditigna. Provided: Construction must be completedwithin three years of the date f this pe Date IJ — Approved by rr Town of Barnstable FfHE r��o Regulatory Services Thomas F. Geiler,Director * BARNSTABLE, + 9� a MASS. ,�� Public Health Division p�ED1A°rp Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Designer: Shay Environmental Services, Inc. Installer: Address: P.O. Box 627 Address: East Falmouth, MA 02536 On ocPa � �i c was issued a permit to install a (date) (installer) septic system at Z based on a design drawn by ad r d ess Shay Environmental Services Inc. dated (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. 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. OF MgSSgcFrG� o CARMEN ns� -Tgnature)alle ' o E. SHAY N No. 1181 0 ��GtS7E�� S PN esigner's Signature) (Affix De i p Here) D 6 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 9/16/03 Notice: This Form Is To Be Used For the Repair Of.Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, !REVIG-4 S\Aay ,hereby certify that the engineered plan signed by me dated OZo concerning the property located at ZB 3 N cj AA"ZS �e meets all of the following criteria: • This failed system is connected to a residential dwelling only...There are no commercial or business.uses associated with the.dwelling. • The.soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests.at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) (P 2 _ B) G.W. Elevation 3D +adjustment for high G.W.J 12 DIFFERENCE BETWEEN A and B , ®� SIGNirD : � V, DATE: 4 ri Q NOTICE Based upon the above information-,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. 5DU-) 2-S Z � gASeptic\percexemp.doc 'ice 3 1 G TOWN OF BARNSTABLE l j LOCATION SEWAGE# y�— / �I P i VILLAGE CernrCzi C O'�- SESSOR'S P&PARCEL .1 -7 ( ~" ®qc� INSTALLERS NAME&PHONE NO, SEPTIC TANK CAPACITY LEACHING FACILITY. e (tyP ) (size) �7 C NO. OF BEDROOMS OWNER t`= P—v PERMIT DATE: C -2Gd6 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 3� �y � 34 A to. � i Aw t Town of Barnstable - CF THE 1p� do Regulatory Services snxrvsras Thomas F. Geiler,Director MASS. •�� Public Health Division lED MA'S� Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 13, 2006 Mr Nick Ptushenko 283 Nottingham Drive Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 283 Nottingham Drive, Cotuit, MA,was last inspected on March 20th, 2006 by, James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The leach pit was in hydraulic failure. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. ,BARNSIABLE HEALTH EPAJRTMENT t:om:as . McKean, R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 283 Nottingham Drive Centerville, MA 02632 Owners Name: Nick Ptushenko Owners Address: Date of Inspection: March 20, 2006, Name of Inspector: (Please Print) James M. Ford f ~ Company Name: James M. Ford c :;;Ij ; Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 `y C CERTIFICATION STATEMENT y I certify that I have personally inspected the sewage disposal system at this address and that the.info ion reported below is true,accurate and complete as of the time of the inspection. The inspection was performed bas d 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 Needs Further Evaluation by the Local Approving Authority ✓ 4ai Inspector's Signature: Date: March 20, 2006 The system inspector shall subi t 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 283 Nottinizhmn Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 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: 283 NottinQhan2 Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2066 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 y Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 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'/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ 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 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. 4 Page 5 of 11 - y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ' 283 Nottingham Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 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 detennined 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 283 Nottingham Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 FLOW CONDITIONS RESIDENTIAL 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): 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): nla [if yes separate inspection required] Laundry system inspected(yes or no): No 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: Pumped in 2005-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 PEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 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: 15" 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 Qal. Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: - 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: How were dimensions determined: Measuring stick Connnents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The liquid level was above the outlet pipe. Liquid was backing up froin the leach pit 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 I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Corn ments(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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 J t� Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 283 Nottinzhain Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -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 liquid was above the cover and flllinz the hole. 1 could not access the cover. The leach pit was in hydraulic failure. 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 i s � Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Nottingham Drive Centerville. MA f Owner: Nick Ptushenko Date of Inspection: March 20. 2006 .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 w"here public water supply enters the building. 3Ac A (3 3 3y� y� 10 r • Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Nick Ptushenko Date of Inspection: March 20, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to detennine 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+water contours map Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable Topographic and water contours maps Maps are showing approximately 30'+/-to groundwater 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 S� Z6 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 283 Nottingham Drive Centerville, MA 02632 Owner's Name: Robert&Jane Yoo Owner's Address: Date of Inspection: September 24, 2001 Name of Inspector: (Please Print) James M. Ford OCT 1 7 2001 Company Name: James M. Ford TOv�-v or D,. .-LE Mailing Address: P.O. Box 49 HEA�TFi DENT. 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 Condi tonally Passes Needs urther Evaluation by the Local Approving Authority iv Fails Inspector's SignatureDate: September 29, 2001. The system inspector shall sub 't 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 I Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 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: ' f 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: 283 Nottingham Drive Centerville, AM Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 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 S i '4141 ti Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone I 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 283 Nottingham Drive Centerville, MA Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 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 ? n/a 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 11 r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 283 Nottingham Drive Centerville, AM Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 FLOW CONDITIONS RESIDENTIAL 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): 220 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): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2000-29 000 gals.; 1999-26.000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAI✓INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on Sept 28198-per treatment plant 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: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 BUELDING 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: 15" 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: 29" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 9" 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.): Tees were present. The liquid level was even with the outlet invert. There were no 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 m x 3,4 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 283 Nottingham Drive Centerville, MA Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 TIGHT or HOLDING TANK: None tank must be pumped at time of inspection) locate on site plan) ( P P P )( P ) Depth below grade: P 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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 283 Nottingham Drive Centerville, AM Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6' H-20 (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 pit had Y of water on the bottom. The scum line was at the same level. There were no signs of failure. The bottom of the leach pit to grade was approximately 86'. 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 i Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) E Property Address: 283 Nottingham Drive Centerville, AM Owner: Robert&Jane Yoo Date of Inspection: September 24. 2001 i 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. I I (3�a� 1-10 A � A i- C) O a 10 Page I 1 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 283 Nottingham Drive Centerville, AM Owner: Robert&Jane Yoo Date of Inspection: September 24, 2001 SITE EXAM Slope Surface water. Check cellar Shallow wells Estimated depth to ground water 30' +/- 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: 4 You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 8'6': Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 30'+1-to ground water at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(SDW 2S2 Zone C 8101)was 2.7. This report has been prepared and the system inspected and passed 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 GrA�Z- i a�•3 1-1i�� Grovn��.��/ �GVz I i GrU c�l.✓.dT/ levc. � � i j 1 i i ', TOWN OF BARNSTABLE LOCAVON 093 SEWAGE# VILLAGE U/TTIr/Ak ASSESSOR'S MAP&PARCEL 171 OA19 IAF&TALW�49 NAME&PHONE NO. U Qln 5 fQ/I• I`"b�'p� !l1�S�D Q�_� SEPTIC TANK CAPACITY UTf(7 �- LEACHING FACILITY:(type) G (size) NO.OF BEDROOMS OWNER t� (J S� �� e PERMIT DATE: COMPLIANCE DATE: Separation Distance Between he: 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 1-^ff7cGTC�1 J FO/� . Q - � � ., 3A�k � . A Q � . . �� a3� a ag a� 3 3 ��_`�� 4 ♦ j F� No. r. FEs...l....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -----OF..... -- ------------------------------- Appliration -fur Biii uiitt1 Works Totui#rurtion Ppruift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal st at: ss ...54.90 .......1�MR) S.ocation `®./Il�._....._.. �� "� ®��o•-----RIPA-�•.................. ...------•-din--• -5/� - .�-- -,.7�. ._tea+. .. .yam r e w Owner OL �\T ............./ s Installer A ress UType of Buildin Si e Lot_--ed ------Sq. feet Dwelling No. of Bedrooms------- ---------------------------------Expansion Attic (A(p) Garbage Grinder (�Ve) pa-, Other—Type of Building U-4414---------- No. of persons........t.................. Showers ( ) — Cafeteria (1&) 0.' Other fixtures _______________________________ __ - �:-&,, Design Flow.............56_.--..__._._.......--gallons per person per day. Total daily flow____-_... �_______._.... ---gallon. WSeptic Tank—Liquid capacity�AQfl_gallons Length---------------- Width................ Diameter-----........... Depth---.._._-_------ x Disposal Trench—N . .................... Width...._.._... Tot Total leaching area____-_____-_..___:_sq. ft. ----------- Seepage Pit No________ _________ Diameter/� _________ e e ow anle .. ...... tal leachil -area..----------------sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed b _ _ __________________________G_---__________-------- Z J"-- Test Pit No. 1................nhinutes per inch Depth of Test Pit.....'_.._.......... Depth to ground water........................ r=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-....._..__--__-_____.-. 6-t------- - -- - ------------•----4 --- - - , , - j''� Description of Soil Q-.= -1 " 'Z_' i c, ----------------------------------------- �1 /.. ---••- u�- •••--�`�`'-�------.------ --------------------------- w UNature of Repairs or Alterations—Answer when applicable..--------------------------------------------------------------------------------_------------- -------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article tI of the State Sanitary Code— The undersigned further agrees not to place the,-system in operation until a Certificate of Compliance has been issu by the b rd of health. SiPan 6(.n Date .�, Application Approved BY- = � fi Date Application Disapproved for tl. _______ ______e following reasons____ ________________ ____ ___ _________ --------------------------------------------------------- Da t e d. Permit No......................................................... Issued...... ------------------------•-- ----------- Date 1 F 7� / fNo..... �--_ ©� (O � Faa... C................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE�AL/T/H . ......--.OF..... , 1_2-)V(.�-!:!��1._-c�(! Application -fur Diapoiiat Works Tutu rurtiutt Vrrufit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 1�j�gy/��g ................................ ..................................................... Lf�l.�ei -Address jot Noj__-..... _ ...................'---....._ ... -- -•--------------•-- I_/�_C.----_.__•__,14-1f- 4!t4. _!- ........................... .......�.".'.!u_:i✓_.... r4 ----------c fV .�Y. Installer Address UType of Building" Size Lot_--/.?j G' ......Sq. feet Dwelling L No. of Bedrooms....__.............. .....-__-_Expansion Attic (Alp) Garbage Grinder Wo) a —Type g FR��4----------- No. of persons------- ----------------•- ( ) — (Ala) Other—T e of Building _.__ ______ � Showers Cafeteria dOther fixtures --------------- ----------------------------•-----------------•-------•------------ ; p._ W Design Flow............:�o_____.___.._.....____gallons per person per day. Total daily flow_-------------------Ll- _______._..._.-------gallons. WSeptic Tank—Liquid capacitvP ..gallons Length................ Width-.__-_.-..-.._.. Diameter_..__.. --.-_-__ Depth................ Disposal Trench—No/ _ ____________________ Vl/idth----------... Tot a� engtlt__ Total leaching area--------------.-----Sq. ft. I r/ �e t e ow inle__- otal leachil trea..___.-_-.-_.--_-sc. ft. Seepage Pit No____________________ Diameter/. ____ 1�/� _ �� g< 1 z Other Distribution box ( ) Dosing tank ( ) O"�� �'_j a Percolation Test Results Performed bY---_---_- ----------------------------- - ------- llat ----------.-.-.--_-----------. Test Pit No. 1-_-_-.______--minutes per inch Depth of "Pest Pit____________________ Depth to ground water..-..---_------.___-__-- (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...._ ___--.---.--.----- ax 1 ' r -! ------- �`=-:4 - ---------`-/--_--- � , ,--• •---- .DDescription of Soil _---- V ------------------ � '•r ?-•--.. x ------------------------------------------------------------------------------------------------------------------ ----------------------------------------------- ------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................____.-.--.--.._.__-_-____.----.--_-.____...._..--------.-.-----_-_-. -- -- ---------------------------•---------•-------------------------------•---------------------------------•---------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 10 i YS. 1,' � --------------;--•J-------------- Date Application Approved BY__-- /_-----�,_..._ .__ ..� �% 7 s--~------- G�iy.l CP-I/J Date Application Disapproved for the following reasons:----_-------_-----------?.................................... ------------------------- ------------------• Date PeiLt No......................................................... Issued....................._ ------.......................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,. ..C2Z!r?t............OF......./ r!...! :1-...../.•..............�.................. arrrtif irate of frompliattrr THIS IS TO CERTIFY, Tdat/the Individual Sewage Disposal System constructed ) or Repaired ( ) by-- = -l`L'�. L t� ..../,,� _ -ut <r/ ----- ----- ----,............... ............................................. Installer at =[ ....._... Il_Llilz �4.�- .��t'�eG�3_et�':�...2Cl_- - l . has been installed in accordance with the p ovisions of Article XI of The State anitary Code as described in the application for Disposal Works Construction Permit No. -,_-' --- dated'__ -' ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD/OF HEALT G�.•.•�-j �j...........OF..-.... .. ..Ll / i..: �/�.................. / No..................----- FEE- ................ . �isvo t;ttt orkii (� u �, � � hilt Van it Permission is reby granted_.___ ----- ��__.__._. to Const�ct or Repair (-)0 an,Y- ividual,.Swage Disposal ystem �C' atNo... ✓�1 �� --------- ---------------------------------- Street ry D '�� — as shown on the application for Disposal Works Construction ; r It No� :_...`.._fir`;�d__.. --. ..........:............. f G Board of Health DATE ------------------------ --� - - TUN FORM 1255 HOBSS & WARREN. INC., PUBLISHERS ��'� r I I i .5745 Trt � ,OAI GONF,�AWS !� /!'fL, 7T" TowN = �i-sue!„" AL J � \ �4Lr4/�. l�`� ?,�J�; �I-� ✓'�7 s Z ,� z5i" a��� �i`1S7" s�4iY0yy/ei4� "AST-, S/ONAL�� No.__ .._ F$$................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ...................... ...................O F.........................................-.....................I.,....................... Applirativii fvr i ipau it Workii Tonstrudivit Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .jjQ: t;Lag 4m..pr,.;...Center..................................le -Lot...21.... 'Qt? .... ................................................ Normest Homes Igcjatlio`,n:Adaress Ashley Dr. , Ceffille ..............................................---.................................................. .................................................................................................. a James Dollowa Owner , Five Corners Rd:d�eSCenterville y s • ......................................... Installer Address 'r UType of Building , Size Lot-..... •5�00D..._.Sq. feet Dwelling—No. of Bedrooms..................... ....................Expansion 4ttic ( ) Garbage ,Grinder ( ) PL,a Other—Type of Buildin qtP f ra_1! No. of persons...................._....... Showers — Cafeteria d Other fixtur s Y: :................ �� W Design Flow......................5.9______________;. 'allons per person per day. Total daily flow........... ..--.........................gallons. W Septic Tank—Liquid capacity._1: - allons Length................ Width................ Diameter................ D!,-�h................ V� x Disposal Trench—No................ .:.. Width_.__Sto4n�e. Total Length..................... Total leaching area..3-:•............sq. ft. Seepage Pit No....................:;Diameter.�?R$..PgPlbepth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (.;�'i')'' Dosing tank ( ) +S aPercolation Test Result: Performed by.....................•---•--••---•-•-•...............•-••-•......-•-••---- Date........................................ Test Pit -_------------minutes per inch Depth of Test Pit.................... Depth to ground water..-..................... fZ4 Test Pit.:No :2.:..............minutes per inch Depth of Test Pit.................... Depth'to ground water.............--......... ....... ..............•-•--•---•------•-•--•••---••••-•---.........--••••--•....•-•-------......._...........•--•-......................----_..........•••.. `0 Description of Soil...-•••••-••-•---•••••••-sand..&...graVel:....----•---•-•--•----------••....--•-••--•-••...------•---•-••••-••••••••-••••-•-------••-•----•---••-. .... r.. ------•-•-•---------------•---------..-..................-----•------•-----•-•---.................................------------•--•--......----------•--•----------•---•-......•••-••---................ U Nature of Repairs or Alterations—Answer when applicable.--............................................................................................. ......•-•----•-••••-••••-•-•---•••--••••••-••------ •---------------------------------- •------------------------------------------------- •---------------- -------------------- •••------ _----_----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si ed. :k ...................••--.........---•--•••• •/o/677..2' ate Application Approved BY--.-- -• - �� � .......................... Date Application Disapproved for the following reasons----------- --------------------•-------------------------------•-------•--------•-••-----......••.............•- ---------------------•--...---------------------.......------------------ ....................-------------•--------•..--....---••••----•-•-----••-•••------•--.....--•----•-......----••-•••-•-•---•-- Date PermitNo......................................................... Issued........................................................ Date Rum .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD ,,OF HEALTH T6wn, ........... ._OF.................. ................ Allpfiration'fo DiIlVo,a Works' (ffollStrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ......................4............................................ ................... ....... Me. L9 ti; Address mtzo.................... ............................................. ............................. .....................*.. Ashley,Dr 3ames Dollo Owner Five Corne' sce .................................Hify......................I............................... ........................ r a 1Wddre ntervillo ................................................. ------------------ Installer Address -c Type of Building. Size Lof.......1-5.t00.0....Sq. feet U Dwelling—No. of Bedrooms...................... ................:..Expansion Attic Garbage Grinder a Other—Type of Buildinygod.......fr...... ... No. of persons........... ............... Showers Cafeteria Other fixtures ... 7­......�­­ ------------------------------------------------- Design Flow............. ----- ..........50................gallons per person per day. Total....daily flow.............................................gallons. P4 Septic Tank—Liquid capacity....1.00palloti5. , Length................ Width..........I...... ................ Depth................ Disposal Trench—No..................... Width s-to e Total Length....................; Total leaching a'rea.'__3jR.........sq. ft. Seepage Pit No..................... Diameter..62A."PaRepth below inlet...................... Total leaching area..................sq. ft, Other Distribution box Dosing tank Percolation Test Results Performed by...... ..................I................................... ........ Date....................................... Test Pit No. 1................minutes perinch .Depth of Test Pit.!......... Depth to ground water........................ Test Pit No. 2................minutes tes per inch, Depth,of,Test Pit....._........_..... Depth to ground water.__.........._.._...___. � 94 .............*---------------------------------------------**----------*.........­.......... .......................................................... 0 Description of Soil...........................sand...&­graveml..........j............................................................................................... W .... ... ............... 7 . U ........................................................................................................................................................._........................................... ---------------------------------------------------------------------------------------**"*'*"***---------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.__.....................:....................................................................... ............ Agreem en t 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 bdn issued by the board of health ...................................... Sied—AW... ....... ................. ................................ Date ed By... Application Approv 7 .................... -- - --------------------_---_ ------_----------- Date Application Disapproved for the following reasons:..... ............................................................................................................ 7............................................................................................... Date Permit No. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH 'Town Barnstable ..........................................OF..................I............7..................................................... f�rrtifiratr of tfoutpliaurr THIS IS TO CUTIFY, That-the Individual, Sewage Disposal System constructed or Repaired by....................................Jame............)110,vmy . .: ........... .............................................................................................................................................. Install Lot 21 Nottingham Drot Centerville at............................................................................................... has been installed in accordance with the provisions of Article,,XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No:_._:____. Okl_72__� dated.......... .................... - THE ISSUANCE, OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ 'Inspector...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' HEALTH . ................Tovn Barnstable ............ ............... ....... ......................... ................ No.---- FEE.... ............... 43isplial I . Por , o tw tru r ffon amiss oJlo''JayPermission is hereby granted........................................7.,.......4...........a.............................................................................. to.Construct ( ) or Repair ( ta Indivigual iewaie'Disp at No................... 21 in nam er.Styt&terville ............................................................................................................................................................................ Street gT lit a as shown on the application for Disposal Works Cori 1 _ 7 7, nstruction N Dated............... ... . .................... -.1af.........................I 011r ie2 ......7 Board off-H-caltl DATE...... ............. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN OF BARNSTABLE LOCATION oZg 3 ( 0,M)"T j 4^-N `'�r, SEWAGE # VILLAGE Cedllr/, I Lk I ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) h (size) NO*OF BEDROOMS BUILDER OR OWNER 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 leachii 9 facility) r° Feet Furnished by T Sa:YVVN (94Lk Al— c*�(o.(o O �. 9, - a3 . pa- A3- *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. 0' min. from vENT PIPE SO Least 24 Inches tall) SECTION A -A ALL p,n�Er�s raw,,,E Schedule 40 PVC w/Charcoal Odor Fit- DMVMYM�yid BE p Existing Foundation �.-.'e to septic tank PROFILE VIEF OF ADDITION TO LEACHING SYSTEM SET LEVEL mR AT LEAST 2 FT. 12' + D-80X cover must be TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septwithin �k Of�� de wahin 6 in. of finished grads ` Grads over Saptk Tank- 99.00 dads over D-Box- 9Y.OD oar SAS- 99.00 3" of 1/8" - 1/2" Waahcd Peasta� t' aF 3/4' to 1 1/2 " Washed Crushed Ston tY WET S - 0.02 3 HOLE H-10 4'PVC(CAPPED)MSPEC110N PORT TO 8E ILA 1 p• EXIST. s,<o m or(ireotw Box 3' Mmrknrsn Cover Top Or Sytwn-Elev. -95.75 MSTAt r m AND TO BE MTRNIt a'OF GRADE +-�.� 1,000 GAL. S- OG1• rRDN Eaasr. raNRDATmrL m SEPTIC TANK 30' per foot O"Efeefhe Depth t•�' / j 9. // 1` a o 5' PLAN SECTION CROSS-SECTION �' n,04 ; r CONCRETE FULL FOUNWQIDN-' m N H-10 N to , 5 Units a 6.25' = 30� /�Fb 1A � �p � • � Sfi�pda 0 tit FMItHNNIM$ C 0.83 (10 inches) 6 b.of 3/4'-, ,/2" -6 N > 3 3a,2s' 3 3 HOLE H-10 DISTRIBUTION BOX Q1� ` .t . : °►�«o SYSTEM PROFILE 2 a, t Not to Scale c COnrpOi R°d stone c o o N w 37 2cJ' NOT TO SCALE > 3.5' 3.5' N Effective Length erpe` s nxLa1 «vLEn 10, o SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES 6 In.of 3/4'-1 1/2' p compacted stone < Effective Vkfth INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN O NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE 0 m° 1. Contractor is responsible for Digsafe notification, Verification of Utilities e (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. w er��� NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" 2. The septic tank and distrl ution box shall be set level on 6 of 3/4 -1 1�2 stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation PERCOLATION TEST by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance Date of Percolation Test: APRIL 1, 2006 with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. Results Witnessed By. WAIVER (Per Barnstable B.O.H.) 6. If, during installation the contractor encounters any EXCAVATOR: Shay Env. Svcs. soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI 0 42" from those shown on the soil log or in our design 100.00' Ph installation must halt do immediate notification be Test Hole Test Hole made to Carmen E. Shay - Environmental Services, Inc. No. 1 No. 2 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS ELEV. DEPTH SOILS ELEV. septic system unless noted as H-20 septic components. 0 99•00 0 99.00 TEST HOLE #2 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Sandy Loom tidy Loom TEST HOLE #1 ELEV.= 99.00 9. All Distribution Lines shall be 4' diameter Schedule 40 NSF PVC pipes. 10 VR 3/2 10 YR 3/2 ELEV.= 99.00 10. All solid piping, tees dt fittings shall be 4" diameter 0"-6' A, 98.50 0'-6" Ae 98.50 7.25' f 6' Schedule 40 NSF PVC pipes with water tight joints. sandy Andy ��.,� z sv'-s 11. Municipal Water is Connected to ALL OF The Residence and Abutting Loam '`�' " Loam e e e e e Properties Within 150 Feet. 10 YR s/e 10 YR 5/6 SHED }l��`•";��-``-'i'' `- l`ti =t THE PROPERTY LINES ARE APPROXIMATE AND 6'- 42" 8e 95.50 6 42' 8e 95.50 4" PVC Medium/Coarse Medium/Coarse Vent COMPILED FROM THE SURVEY PLAN GENERATED BY Sand saris BAXTER do NYE, INC. of OSTERVILLE, MA ENTITLED"CERTIFIED PLOT PLAN OF LOT 121 KNOTTINGHAM DRIVE, CENT. MA 2.5 Y 7/4 25 Y 7/4 Failed DATED AUGUST 14, 1975 42'- 132 G lag.00 42"- 132 G amg Leach Pit AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN IT SHOULD BE USED FOR NO PURPOSE OTHER THAN PROJECT BENCH MARK THE SEPTIC SYSTEM INSTALLATION. TOP OF FOUNDATION 99 --- -------------------------- --------------4f --------- -----99 EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE ELEV. = 100.00 (Assumed) i p, EXIST. 1,000 GAL. I I SEPTIC TANK NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE I I FROM THE EXISTING LEACH PIT TO BE DISPOSED O LQJ OF AS PER BOARD OF HEALTH SPECIFICATIONS. O Perc1 RO PATIO THERE ARE NO WETLANDS'ARE PRESENT WITHIN 200' OF THE PROPERTY Depth to Perc: 42" to 60" O Perc Rate= 2 MPI O ASSESSORS MAP 171 PARCEL 049 Groundwater Not Observed EXIST. C No Observed ESHWT 28� GARAGE LEGEND ADJUSTED H2O Elev. = None w EXISTING JW,HOUSE 104X1 DENOTES PROPOSED SPOT GRADE 2-18' DIAM. ACCESS MANHOLES rr X 104.46 DENOTES EXISTING f� -.�• =;-: - ::� 99 --- ------------------ ------------ ----------I---- ----- 99 SPOT GRADE EXIST. I PL PROPERTY LINE DRIVEWAY I 96 PROPOSED CONTOUR OU'll ET V r` THE ACCESS COVERS FOR THE SEPTIC TANK, LOT #121 ----- -97 EXISTING CONTOUR _ DISTRIBUTION BOX AND LEACHING COMPONENT I SET DEEPER THAN 6 INCHES Baow FINISHED 15.000 Square Feet + GRADE SHALL BE RAISED TO NATHM 6' OF L STEEL REINFORCED PRECAST CONCRETE F NGRED GRADE I DEEP TEST HOLE & PLAN VIEW INSTALL TUF-TOE GAS BAFFLES OR EMALS � PERCOLATION TEST LOCATION 98 --- --------- ----- ------------ ---7----- 98 -------�---- 3-24' REMOVABLE COVERS 1- ----- 6 FOOT STOCKADE FENCE RZ 3" min. Clearance 13' NET NVLET 8' min - Y min. Irdet to outlet s. - to'mtn. Llqu� OUTLET y -/ \- V -7' : : 5-7• P LOT P LAN >;s on soft LrIqui�dAepRfr KNO TTING AM DRIVE OF PROPOSED SEPTIC SYSTEM UPGRADE _ PREPARED FOR i -:,�•_-�. ::,,.1.. ; . -_-,. :p (40 FOOT RIGH OF WAY) Ire- 4' -,a' NOCHOLAS PTUSHENKO CROSS SECTION END-SECTION AT TYPICAL 1000 GALLON SEPTIC TANK #283 N OTTI N G HAM DRIVE NOT TO SALE CENTERVILLE, MA Design Calculations Kitchen g EXIST. Bedroom Bath -JN of PREPARED BY: /Dining GARAGE �- ss Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gal./Day Min. per Title V) e� C RM�'N E. ASH�1 Y Garbage Grinder: No R •- GNP Leaching Capacity Proposed: 330 Gol./Day Minimum (Min. Per Title V) E. Septic Tank : - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. Bedroom AY NVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./'mch Living Room 0. 1 Bottom Area: 0.74 gal/sq. ft. x 372.5 sq. ft. = 275.65 gallons o ' .0. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 78.72 sq. ft. = 58.25 gallons 0 20 40 50 �01STER� EAST FALMOUTH, MA 02536 Providing: = 333.90 gallons I I I I NITAR\P� 2 BE HOUSE FLOOR SCHEMATIC TEL/FAX 508-539-7966 Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1«=20' DRAWN BY: CES DATE: APRIL 4, 2006 TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1"=20' ON THE ENDS. No STONE UNDER. PROJECT#SD892 FILENAME: SD892PP.DWG SHEET 1 OF 1