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HomeMy WebLinkAbout0300 NOTTINGHAM DRIVE - Health 300 Nottingham Drive \F Centerville A = 171 -041 kw S M E A D No. H163OR UPC 10259 smead.com • Made in USA 2 1 3 j' Commonwealth of Massachusetts Title 5 Official Inspection Form �s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms ' on the computes, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections r� Company Name PO Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ou/j 07/15/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. �6. ****This report only describes conditions at the time of inspection and underthe conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 6 Official Inspection orm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11110 Title 5 Oftial Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Citylrown 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 pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich 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 Wns 0.V'i0 Tfle 5 Off cial lnspeCion Form.Subsurtace Sewage Disposal System-Page 3 of',7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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/day flow t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityfrown 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ' 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of ate D occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 ` 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 02/08/12 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.7 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: 1.9 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 gal 3" Sludge depth: t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 T tle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 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 even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. 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 Forth:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): This system has two 500 gallon drywells surrounded by 3 of stone.There was no sign of ponding or failure in the stones. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of pending,condition of vegetation, etc.): t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: Z hand-sketch in the area below ❑ drawing attached separately 1 �3 � � r �g t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments > 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityrrown 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: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators,installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lns•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Nottingham Drive Property Address Gordon Pyy Owner Owner's Name information is required for every Centerville MA 02632 07/15/12 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 300 Nottingham Drive E _; Centerville MA 02632 "y Owner's Name: Sy Zarthar C:; a Owner's Address: Same Date of Inspection: January 20,2007 Job#07-07 Name of Inspector: PATRICK M.O'CONNELL t; Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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\��,DEP`"` n 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 Approvin uthority C ; X Cam_ t�-S� Inspector's Signature: --�--��--- f . Date: 1/20/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching chambers are full overtop of structure. ""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. Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 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 sept ic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally P ill ass inspection if the unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will p 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: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address:300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 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 I 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma _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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:300 Nottingham Drive,Centerville . Owner: Sy Zarthar Date of Inspection: January 20,2007 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems:? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ Existing information. For example, a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms):330 Number of current residents: 4 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): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/IN DUSTRIA L 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: Tank pumped 20 months ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/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: 1998 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: 2' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of certificate) Dimensions: 8.5'long x 5.2' wide- 1000 gal. 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank is full to top. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 TIGHT or HOLDING TANK: No (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: XX (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.): Full to top. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: _X_leaching chambers,number: Two 500 gal drywells. 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.): Liquid level in chambers is over top of structures. Leaching system is in hydraulic failure CESSPOOLS: No (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: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 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. ... ............... .... ....... 34 42 27 Nottingham Drive i Page 1 I of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:300 Nottingham Drive,Centerville Owner: Sy Zarthar Date of Inspection: January 20,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: _Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perc test will be performed prior to inspection to determine groundwater elevation. _ - -- TOWN OF BARNSTABLE LOCATION 300 Nagi tc ,4 of SEWAGE # VILLAGE CE�f1F1"�//� ASSESSOR'S MAP & LOT/9/-/22 INSTALLER'S NAME&PHONE NO. S7 -5''10-%7-58 c/4,5!5 `R t14Rr,&S SEPTIC TANK CAPACITY _1(JOD LEACHING FACILITY: (type) 2 S40 ��i9�,d c'/"S (size) /5 X ::?r NO. OF BEDROOMS BUILDER OR OWNER 10 Z/9/?J1I /^ PERMIT DATE: — 7 4 COMPLIANCE DATE: 2 - R- 0 7 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 leac 'ng facili ) Feet Furnished by !d.°✓t+o'd� � ��yi��,<,Uv�! I ' �' � .. s� , -8b� '�, ss ,�� "£�£ b -��,:/ No. z V 1 Fee l THE COMMONWEALTH OF MASSACHUSETTS Entered in computers✓r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - Rpplicotion for Oioo al *voem Cow5truction Verm tt Application for a Permit to Construct(4.r Repair((KUpgrade( ) Abandon( ) ❑ Complete System L Clndividual Components Location Address or Lot No. ado No?T�N� rl✓- Owner's Name,Address,and Tel.No. 11 G�NT� /,;�� 5� ,. zorTG,w - Assessor's Map/Parcel 7� (�� os s� Installer's Nam ,Address,and Tel.No. S 7y Designer's Name,Address and Tel.No. Type of Building: �iflJ e re✓'Dy (J�r^^,� '^ �0 �1 Dwelling No.of Bedrooms Lot Size - sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �( 'Uw Type of S.A.S. O� 13. 2 1/ Description of Soil Nature of Repairs or Alterations(Answer when applicable) ZhtST�vl� - 5aO 1�0/. /��d [,h l9Gh�y��/ 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 ealth. Sig ,r/U Date Application Approved'by, Date Application Disapproved : Date for the following reasons Permit No. �0d —U y Date Issued 0- 7 6 -7 ... .::�,-.: .,�.... ....:r..--•--......,.r,..:.--•..� w-i:-+.-,+'7-.:.ii.w.a-v ..� .•...Y�..�...�.. 'iy,{w'.�s..y:+�^^+:� .. « �.�..., . .. .-w..s'•z�-..:��..:_:..., ,..� ... ...,y:.a...- ,. -.r - .. wv..� ... r. r ` r No. _ )(2 --0 , ,., $,. Fee 1 U 0- fT THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 2 PUBLIC HEALTH DIVISION - TOWN OF.BARNSTABLE, MASSACHUSETTS YeS r _ i ZIPPYtcation for �Digpogat 6p5tem Con5truction permit Application for a Permit to Construct(4,Y Repair((rY Upgrade( )` Abandon O ❑ Complete System Individual Components Location Address or Lot No. 300 1V19 r1/N��1� rl Vf= Owner's Name,Address,and Tel.No. I rrrvrl rI Sy Z,��Ttiwr Assessor'sMap/Pazcel C/� Installer's Name,Address,and Tel.No.Sd$-��D- 77 S2 Designer's Name,Address and Tel.No.SGg" y77- s 3X 3 Oe "f-` Wal rah,` OV,15 /2 1,(/. G o S Fii=!e'l ll 1d 5 0;AA u/i C4 Type of Building: CA -"-rJ k rfv'Dy �rA^14 't V,4 90 — �f Dwelling No.of Bedrooms 3 Lot Size r sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures x' Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title ` l Size of Septic Tank X UdJ Type of S.A.S. �?T�6 r `, r.., 13. 2 I X2 Z ✓1 Description of Soil r Nature of Repairs or Alterations(Answer when a D (o� pplicable) _�/`/�T,4�� �- SU >' n-2G GNlQGI�!/H�/ .,` I Z 11:5'r lJ�i�- Date last inspected: 4 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 eeaallthh.. Sig�ed 1/ r/�f r�/I�i"?/, Date r Application Approved by Date "7 d 7 Application Disapproved y: ; Date for the following reasons c . . Permit No. �0� �'/ - U y Date Issued a a THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ('-) Repaired (4-1 Upgraded ( ) Abandoned( )by 5 x�"I fs�vU 3 at 300 /J//>1Gid1,14,w y�". 61= zrx-- 'V ll has been constructed in accordance with the provisions of T//iit�tle 5 and the for Disposal System Construction Permit No. Ud 7 0 t�t� dated - /h/G Installers �S!_/�� L Z1_1,i^e��f Designer F,t1GiH�=/-_'!i/sal/ GJ/oYK S r #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will f nclti n as designee). Date A k I 0-7 Inspector No. r?0 o 7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lfg"oo 6pgtem Construction Permit Permission is hereby granted to Construct (li) Repair ( G) Upgrade ( ) Abandon ( ) System located at 1"'w N"1z and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Cons ruction must be completed within three years of the date of this/per)mi Date -7! v2 Approved by A1 +, 11 ) �1 rI rr*l 'r`n a/ iN /P�.,, �� W1 -'/hrn�c'r. .� �a/IP� 017/07. 1 e4 �,� cP✓hs., Town of Barnstable oFT"E r°w Regulatory Services Q� o Thomas F. Geiler,Director + B"NSMBM MASS. g Public Health Division 16,39. '°rFc►ray" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: ?A'A6_7 Sewage Permit# VY Assessor's Map\Parcel "7) J deb �s �e� 4� c . Designer: E��� rca.,R'y�� U'l�rw� Installer: Cr Address: Z. 1i�J less ��Q�� (2d Address: g Co.M On b c SV' was issued a permit to install a da e) V (install r) septic system at 306 fJd i} t n �\ci V'1 r . C�� based on a design drawn by (address) �C�h£✓�� �V� fee �. dated 2��Q L �2 )Z� ,,l C7 (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. Stripout (if required) was inspected and the soils were found satisfactory. . 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. Stripout (if required) was inspected and the soils were found satisfactory. Mq f f9�y DAIJ ;NA((��-� o PETER T. (In to er's ignature) oe vtLE N No. 35109 SSIONMU E�G� (Designer's Signature) (Affix Designer's tamp Here) 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:\Septic\Designer Certification Form Rev 03-09-06.doc TOWN CAE ARNSTABLE ,OCATION . � �r''t 1 `ot^ 40r SEWAGE # 0,11e_ . ___,___ASSESSOR'S LOT -_ NSTALI-ER:S NAME PHONE NO. ;EPrC T,4NK,CAPACrry .EACHNG''FACILITY: (type)���`� rs (size) 10.OF BEDROOMS WILDER OR OWNER 'ERMITDATE: COWRLIANCE DATE: separation Distance Between the: rlaximurn Adjumd.Groundwater Table to the Bottom of Leaching Facility Eget Irivate Water Supply WoM and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) idge of.Wedand tuid Leaching Facility(If an Hands exist � within 300 feet�f leaclun$$,,facili�) �® eet -turnished by c��y /1 w�l/y, G`t® / C�� `�`r B �a �d„er 0 0 o � A -0-3q Q-D- l 3 A -F-- 35Z le -G- 36 2-4- Sy s Town of Barnstable P,- # ( f 3 3 Department of Regulatory Servic N MAM Public Health Division q c 19. 200 Main Street,Hyannis MA 02601 Date t z 94 Date Scheduled S A7 Time--= Fee Pd. 0 Soil Suita�ility Assessment for Sew e D' Performed By: 6�, r g asposal Witnessed By: LOCATION& GENERAL INFORMATION Location Address UD N O ++h n,(,W,of D n Owner's Name Say Address S� Assessor's Map/Parcel: �'-'� i _ � y , Engineer's Name �1 c NEW CONSTRUCTION r REPAIR ' Zv C r t I C C✓�}�� P n Telephone# ��U��" -7; -5 3 13 Land Use i�-eS �I1V-4-�CA i Slopes(�/a) Surface Stones Distances from: Open Water Body �C,>i'J �_ft Possible Wet Are;, ft Drinking Water Well Drainage Way-2 L U`J ft Property Line �d --__ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximityto holes) oles) ----------------- <a I a H-IN /1s hcA,,�A p f Parent material(geologic) 1.0�C_i OA ©J r�S v l Co ryl Depth to Bedrock 2 C Depth to Groundwater. Standing Water in Hole:_ ! /-r n , 1----�--___- Weeping from Pit FpCe Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE ,� / Depth Observed standingin obs.h /V/ . hole: Depth to Weeping from ' in. Depth to soil mottles: P g aide of obs.hole: In. Groundwater Adjustment in. �� -� Index Well# Reading Dater Index Well level (t• �- Adj,fhctar �,sT - Adj.dmundwaterievel,� PERCOLATION TEST bate z s — Observation i x'In1e�� Hole# , 'i,� 1 Time at 4" ._ tt t t Depth of Pere Z Time at 6" Start Pre-soak Time @ 1 L (-S—- Time(9"-6") _ End Pre-soak. �,o _S �l r0\ �( Rate MinJMch C Z {mot n it I I- M^ AJ� 2(•i U t Site Suitability Assessment: Site Passed _ Sitc Failed: Additional Testing Needed(YM) 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.OBSERVATIONHQLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. an iste c % ravel 0 - 1Z L L 3 IZ- 20 � S L l 0'l'4 /3 Zo - Lta 'a L 10 Y ►Z s/. ('A—C St,,"vt Le `to.rZ 5/4 IQ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel LL 1 — 22 A laylz 313 22- 42 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. consistency,%Gravel i 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 „ Within 500 year boundary No-2 , Yes , Within 1.00 year flood boundary No 1�, Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y =— If not,what is the depth of naturally occurring pervious material? Certification I certify that on l k K-(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CNM 15.017. Signature Date Q:\SBpTICVERCFORM.DOC I Y Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M a 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information II 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 C M R 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalu ton by the Local Approving Authority 6-30-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. LZ t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposa ystem-Page t of 15 • 1 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 6-30-10 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 A) System Passes: ® 1 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: System is in good working order with no sign of failure. 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 stat ic 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 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: El 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.env iron ment: ❑ 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: f ❑ The system has a septic tank and soil.absorption system (SAS) and the SAS is within i 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. t5insp official document-03/08 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 l ❑ ❑ 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. t5msp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts U W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were'any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection 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 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)): y Sump pump? ❑ Yes ® No Last date of occupancy: 4-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page, City/Town State Zip Code Date of Inspection D. System Information (coot.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No I If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: i 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): Approximate age of all components, date installed (if known)and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 24 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal Sludge depth: 16" Distance from top of sludge to bottom of outlet tee or baffle 16" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Tape t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 16 I I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 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.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet 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): t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑, Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document-03/D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7M 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ '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.): Leach chambers in good condition and empty at inspection with stain line at 6"from bottom of chamber. t5insp official document•03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-.800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name - information is Centerville MA 02632 6-30-10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. . Cjkrw;ye. 8 �oucc D Q 1 -356" F_ i t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Nottingham Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 6-30-10 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: 10, 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: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 10'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 S' t COMMONWEALTH OF MASSACHUSETTS ^ fr EXECUTIVE OFFICE OF ENVIRONMENTAL RS , DEPARTMENT OF ENVIRONMENTAL P COTI ONE WINTER STREET. BOSTON. MA 02108 617-292-_ Cr 8 rg WILLIAM F.WELD Y CORE Governor Secretary ARGEO PAUL CELLUCCI �ID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION 300 Nottingham Dr Harvey & Marsha Gladstone Property Address: Centerville MA Address of Owner: 50 Thistle Drive Date of Inspection: 8-26-98 (If different) Centerville MA 02632 Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Servi Mailing Address: PO Box 1089 , Cent-prvi 1 1 Py MA 02632 Telephone Number 5 0 S ` 77 5—A 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site seaa disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: i4Qv Date: a--�i!/ The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, of D: A]7M PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: YSTEM 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. Ind' ate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The.septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Copliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep f J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 40� PART A CERTIFICATION (continued) Pro e�rt' ddress: 300 Nottin ham Dr Centerville p y 'wI g r kOwner:: Gladstone Date of Inspection Y8—2 6="g 8 SYSTEM,CONDITIONALLY PASSES (continued) _ tSew ge backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: li broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ FUR HER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or.privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL.FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (zeviaed 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8—2 6—9 8 D) SYSTEM FAILS: You ust indicate ei,?,er."Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any,portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE S STEM FAILS: You must i dicate either "Yes" or "No" as to each of the following: T e following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: Yes N the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply.well) The owner or perator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements f 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8-2 6-9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No f✓ _ Pumping information was provided by the owner, occupant, or Board of Health. (� None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _✓ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8—2 6—9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: "ISO g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no): 6 Laundry connected to system (yes or noVd-5 Seasonal use (yes or no):�U Water meter readings, if available (last two (2) year usage (gpd): 1st 6 mos 1998 62, 000g Sump Pump (yes or no):_ 1997 145, 000g Q^ 1996 189, 000g Last date of occupancy:U 'igC—� COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS nd source of information: '6' A System 11umped as part of inspection: (yes or no),4k p If yes, volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)/e a (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8—2 6—9 8 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distancejfrom private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: 4/ (locate on.site plan) i 1 Depth below grade: Material of construction: _concrete _metal _Fiberglass ._Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: L a A & '(. ' Sludge depth:_ ' Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 ' 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 dimensions were determined: D 'L%A i d < Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, epth of liquid level in relation to outlet invert, st ctural integrity, evidence of leakage, etc.) -Z O 5, b ► GREAS TRAP: (locate o site plan) Depth be ow grade: Material f construction: concrete _metal _Fiberglass _Polyethylene —other(explain) Dimen "ons: Scum ickness: Dis nce from top of scum to top of outlet tee or baffle: Distance rom bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comments: (recommen ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a idence of leakage, etc.) (revised 04/25/97) Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8—2 6—9 8 J TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate site plan) Depth bel w grade: Material o construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensio Capacity: gallons Design fl w: gallons/day Alarm I el: Alarm in working order_ Yes; _ No Date of evious pumping: Comments: (condition inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: t/ (locate on site plan) Depth of liquid level above outlet invert: O Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - L Z L� - i PU CHAMBER:_ (locate on site plan) Pumps n working order: (Yes or No) Alarms in working order (Yes or No) Comm nts: (note ndition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8-2 6-9 8 / SOIL ABSORPTION SYSTEM (SAS):v (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number:-2--- leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSP OLS: _ (locate n site plan) Number nd configuration: Depth-to of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensi ns of cesspool: Material of construction: Indicati n of groundwater: inflow (cesspool must be pumped as part of inspection) Comments (note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: �' ) (locate "site plan) Materials o construction: Dimensions: Depth of so'ds: Comments: (note condit n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8—2 6—9 8 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i r c9r � r �"cV �O (revised 09/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Nottingham Dr, Centerville Owner: Gladstone Date of Inspection: 8—2 6—9 8 Jr Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record __L20bservation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps a Check pumping records Check local excavators, installers Use USGS Data , Describe in your own w rds how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 TOWN OF'BARNSTABLE .,LOCATIONi4_ V b �1 tQ J114 M V k SEWAGE # ,y S 3 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. l .SLY�s L -7 07 7 4 SEPTIC TANK CAPACITY —6 5 LEACHING FACILITY: (type) 07- (size) '' NO.OF BEDROOMS BUILDER OR OWNER e:e:�/,4 PERMITDATE: �"'�3 `� COMPLIANCE DATE: 9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the B/etlands hing Facility Feet Private Water Supply Well.and Leaching Faciliells exist on site or within 200 feet of leaching facility Feet Edge of Wetland and Leaching Facility(If anyst within 300 feet of leaching facility) Feet Furnished by �' � J r �1 f e �'. '3'.�° ° �� � �. .. `a' ' �� ���� .. I ` Fee $5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Migpooal *p5tem Cungtrurtiuri permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 300 Nottingham Dr Owner's Name,Address and Tel.No. 7 9 0—7 3 4 9 . Assessor'sMap/Parcel Centerville Harvey & Marsha Gladstone 50 Thistle Dr, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service P 0 Box 1089 Centerville 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of D—Box and two 500g stonepacked precast leach chambers 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 Env'ronmental C e and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this d ealth. Signed a n Date Application Approved by Date Application Disapproved for the following reas n Permit No. �Date Issued s TOWN OF'BARNSTABLE LOCATION . �� J/o f / r n r 4 X, 71 SEWAGE VILLAGE_ C. �. �i 4SSESSOR'S MAP& LOT _ p INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) !i ,=—i4 C NO. OF BEDROOMS 3 BUILDER OR OWNER�/;,i 76 n L PERMITDATE: F -/7 — `J r COMPLIANCE DATE:U Separation Distance Between the: Maximum Adjusted Groundwater Table to the B/etlands hing Facility Private Water Supply Well and Lea Feet PP Y clung Facilityells exist on site or within 200 feet of leaching facility Edge of Wetland and LeachingFacilityyFeet within 300 feet of leaching facility (�anst Furnished by Feet 01 _j3 Fee 5 O.00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprfcatfon for ;N.5paal *pgtem Congtruction Vermit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components i Location Address or Lot No. 3 O O Not t i ngh�m Dr Owner's Name,Address and Tel.No. 9 O—7 3 4 9 Assessor'sMap/Parcel Centerville Harveyy & Marsha Gladstone 50 Thiskle Dr Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service P O Box 1089 Centerville 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( n6 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting sting_ of D-Box and two 500g stonepacked precast leach chambers Date last inspected: f 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�thheEnv* tal Code and notto place the system in operation until a Certifi- cate of Compliance has been issued by this r Signed Date v Application Approved by aDate Application Disapproved for the following reas Permit No. _ Date Issued s, THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE, MASSACHUSETTS Gladstone (Certificate of Compliance " R � THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ).RepFa`ire' d(xy)Upgraded( ) Abandoned ( )by fT at 306Centerville lj has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nod 4,° 53qated Installer W E Robinson Septic Service Designer ,f 7, The issuance of this per t sh no be�° trued as a guarantee that the s stem wi 1 function designed. Date p / g. Inspector y g Fee 5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Gladstone Mtgpogar *pgmem Congtruction Vermit Permission is hereby granted to Construct( )Repair.( X)Upgrade( )Abandon( ) System located at 300 Nottingham Drive Centerville batal 1 ar W E Robinson Septic Service and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructio must b comD eted within three years of the date o 1 ermit. L Date: Approved by 1 A x NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at 300 Nottingham Dr, Centerville meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) / ,l 9 v SIGNED:! F DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20_1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). r FRis a r` 1/V TKE COMMONWEALTH OF MASSACHUSETTS lo �x BOAR® OF HEALTH �`�G✓`^ -- ........OF......-,......v.....S77#"'O� Ia� ApplirFation for Uhipvii al Works C ontitrurtion ramit "Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: `a / ,.,',_ ----••••---•••••••--•--••--• -••---•-•---•••• ._......---•••-..._._...••--•••••-•-•-••-•.............................•--•- Locati Pddr ss or Lot No. l .C..........`►✓ . .:t f t9 r^ 2 ...................................................c9 a / O ' Q!'' ... f..( _� ^ _.. Own Address .1 gyp✓/1 �"/� �,yA➢ �. �Y b I �9 an j Z�1. li�fA -ai'a.•T�L.OI n..V� ...C:.C.. Installer Address d Type of Building Size Lot............................Sq. feet ___________________________Ex Garbage Expansion Attic Grinder Dwelling-No. of Bedrooms_____________ p ( ) g ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------•-----••••-•--•-- WDesign Flow___________________________________________gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_._.__.____gallons Length................ Width................ Diameter________._____-_ Depth................ x Disposal Trench—No_____________________ Width_.___.._________ _ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter....... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.-----------------------------------••-----------------------•---....---- Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i L'Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water_______________________. Descriptionof:Soil • .-'.--�f-•-----------------------------------•---•--------------------------•-------------•---------------------------•----------------------- x -,- x ------------------------------------------------------------- ...................................... ------ Nature of Repairs or Alterat s—Answer w en appliclble_______ 10....__1 Wit?_✓_ 'f !t. -�- �,&. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLIJ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s been issu d by the board of health. -------------•------------------------------ f % to Application Approved By... == ........................... / �f --•-•-•••..._••--__•---•• ••--•-•••--•---- ...................... Date Application Disapproved for a ollowing reasons---------------•--••----------------------•-•---.._.._-•--------•-•-•-•---------•----••--•-•-•-------••--------•- -•._._...•••-••••--•----•••.........................•-•--•---.......•--•-••----._._..........-•••---...•---•-•---••-------------••---•••--•---•....-•---•---•-----•--•-••.._.---••---------••--•-•...... Perm' it No......................................................... LIssuedL------•-••••--•--••-•---•--•-•- Date VO -CAl;10N SEWAGE PIT NO. VILLAGE INSTALLER'S NAME i ADDRESS J. G MEDEBR®S Trucking & Bulldozing 4-2 E1,71-3v llon Street Hyannis, Mass. 775-0828 OM OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r r I No. "'� ..... Fis.... ............... THE COMMONWEALTH OF MASSACHUSETTS �_. . BOARD OF HEA}LTH ' .r"�.hA._.. ......oF................�'.°Y.. `a( ram° ............. . .. ....._..._...._..------------..................... Appliration for Ui ipas al Workli Tnnitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair. ( ) an Individual Sewage Disposal System at: .............................----•-•-••-•-••------•-------• .............. •....------..................---------.................----------------------...............----•- Locati ddr ss A ' ..��,Pr Let NoA Add �a N +'lre7� ----------- --------- ................. ! ..................... ..... ...•-•-----------. Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date--- .................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil.........: _?...`' : . W V .........---•--•--•--••-----•-•••-------------------•••••-----------•--•-----••••-•••---•--•--•-•-•-••••---•----•-------.._...---•••-•-•-----•- ......................................................... W ••-•--•-••••----••---------•-------------•-•--•--••------•----------------------•-••--•-----------•----••-----•- U Nature of Repairs or Alterat' —Answer w en applicable-------- --------_/_.�?'a'+� �!� °'`_ I/?�'r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE '5 of the State Sanitary Code— The undersigned further agrees not,to place the system in operation until a Certificate of Compliance Ws been iss d by the board of health. nc • - --- •--- -. ._ ---------------••----.----•-•---- e Application Approved BY---------`-------"��"��-r�'�-�.............•-•--------- -• -------- '''N-.."��.`'.1 ---...._.. Date Application Disapproved for he, llowing reasons:-•-•----------•--•••-•------------••-•-•••--••-•...•-•---••---•----------------•--•-•--••-•--••-•-•--........... •--•--•-•-•---•-----•---••-•------•-•-------•--------------•-•---------------------..........-------•----•••------•----•-•••-••--•-•------•-------•-••---•---•-----------------••------•••-•----•-••---- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF. /. ... '........................................................... ( atifiratr of Toutpli anrr THUS IS TO CERTIFY Thal the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..---- '.., ....._..... '? .S'r►4 ---•--..... "Q Y �•�y� Installer . .-- ............ ---•-------------•--•--•----•----•--•--------------•---••-•-•--•-----•---------- has been installed in accordance with the provisions of T l � ` of The State Sanitary Co a escribed in the application for Disposal Works Construction Permit No._ `�_ 7.................... dated_l_.. f f.. ......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM Wl FUNCTION SATISFACTORY. DATE... ..., .::...... ... ...... Inspector•-•-- -•-•• •---......_......•-••-•-••-•-•------------••-----............._--•••- i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.C �.. � .......OF...�......�": '.•^.`....................................................... r✓ � ..._ FEE ...-•---- ..------ f! 42 �i���a� 1 r�� C�nn��rnr#ilan rrani� - Permission is hereby granted........ ......... .. ..__ ..gyp__... / " ........0,9A ^ to Construct ) Repair ( n Individ I S Wage Disposal stem at No.. -f�'t + - - b -,-.-°-` ._.L........_ '� a Street as shown on the application for Disposal Works Construction Permit No____ __ _______ ted.._._ /. ......... ,�,,... 2 ----------------------- ----- ••-- --•- - �i//3 DATE........ •-...----•-•--...--•-•-••--------•---------•-----------•---- Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS / No.---. ....[. X ... F$ic........................... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L ................ OF... &Vptiration for Biiipviial Worko Tonstrurtion ramit Application is hereby made/for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at...... .. ........ .. . j ................. ress b ............... .�pocatio�t�Add. .. ... ...... .............. .................. ... ..�QA o Lot No........ .,....................._ w Ad- ...................... . ... ......O L �� .............. .....'_QJ. ..._ .. ... ... .. a..... ..---•••••••_..... Installer Address Type of Bu ding Size Lot....... .........Sq. feet U Dwelling—No. of Bedrooms....... .............. ..................Expansion At;ic ( ) Garbage Grinder ( ) Other—Type of Building Y �- No. of persons............................ Showers ( } — Cafeteria ( ) d Other fixtures w Design Flow__________________. _...._._............._.gallons per person per day. Total daily flow.......... Q .................... WSeptic Tank—Liquid capacity/d .gallons Length................ Width......_......... Diameter................ Depth................ x Disposal Trench—No..................... Widi Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... D Diameter_ below_inlet....._.........._... Total leaching area_.7.9?-._.sq. ft. ___ Z Other Distribution box ( ) osnk ( ) aPercolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. 1.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -• Description of Soil......... x U ......------•-•-••--•-••••--•-----------•••-•-•-•-•••-•-----•---•----•------••••---•--••---••-•-•--------••-•••••----••••-•-•-••-••••••-••--•-----••••-••----••••••--•--•-••-•----••......-•••-••---••... w V Nature of Repairs or Alterations—Answer when applicable................................................................................................ ....-••...-••-••----•-•••••••-••...-•---•--•-•••........•••••••-•••••-------------------------•-•-•------•--•••------••--•----------••-••-••-...----••••---••-----••••-----•--•-•-••••-••............_.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co —The under igned further agrees not to place the system in operation until a Certificate of Compliance has been ed by/t and health. Sied__5 1,� .............................. --. - 40 Dat Application Approved By___... / ate Application Disapproved for the following reasons------------------- -----------------------------••--•-•-----.•.... •••...........------.... -----•---•-------------------------------------------------••----------------•------.......---------...----••••-•••-••-•--•-••---•--••---••---•-•••----------••••................................. .. Date PermitNo......................................................... issued........................................................ Date t , No..... .--./••---• F$$..... ,:................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y cry.................OF... Alip ira#ion for %iVasat i5arkii To'nstrudilan Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual,,Sewage Disposal System at ff ................` .... ' .r . N y. .: i'i:r.. :r�.}�?du yi b -•• �dte'1&......... ...... ..,,,' .. . ... ..... ocatto Address �f $ r Lot No. W {` owner .............. Add 1 ....<a. .....V�' =t.riax._: 7­17 ............. ..�.:�.'�"� ?...._. 't�?�4":.ay._....S �_.�. ...................._..'- Installer Address Type of Bi ding Size Lot..._. ....-...... ._Sq. feet Dwelling—No. of Bedrooms._......._. `..............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building 1 ". •�:.��jt; *:n!� No. of persons................ ........_p Showers ( ) — Cafeteria ( ) Otherfixtures ......•-••-----•--... .--••--•.............................•--------....---................................ W Design Flow....................-!2.........�.....gallons per person per day. Total daily flow.............„'':�:�....._..._.........._.gallons. WSeptic Tank—Liquid capacity,6rD' .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width—,_ K ........ Total Length.................... Total leaching area....................sq. ft. ..� � Seepage Pit No..................... Diameter bepth below inlet.................... Total leaching ft. Z Other Distribution box l7osing tank ( ) Percolation Test Results Performed bv..............:...........•--.......-•-........---•----............--..... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground 'water--_--._.-__-___-_______- f-T-1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil...... ' r ` x ---------------•-•---•-------•---------------------------•-----------•-....-------•---------------••-•--•----..... V -------------- ---------------- --........... •--------------- •----------------- •------------ •------------------------- 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 Cog�e—The unde igned further agrees not to place the system in operation until a Certificate of Compliance has been " Ied by t• oard f health. Si ed. - �" :-- �5-Av - t �^ E � - Dat Application Approved By { , J} -------------- ' ate Application Disapproved for the following reasons:------•-••....................•••---••••---••--•------------•---•-------••••-•-••••--•-•----•---••......•....... • ....---•----...-•----------------------••..........-----•••--•••----•------•......--•--•••---•--•-••-•--•-•-----•-•••••--•--....... Date PermitNo........................................................... Issued........................................................ Daie THE COMMONWEALTH OF MASSACHUSETTS r BOARD HEALTH ...................... f ;'✓ i'✓» u Trrtifuatr laf Toutpliattrr THIS IDS TO CERTF- X1 hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Yw ............................•---.--•-- . ` zliistaller �_.. has been installed in accordance withathovisions of Article XI of hi�e`` State Sanitary Code a des ibed in the application for Disposal Works Construction Permit No................. .�� ......... dated._- _2 ..1,777..;�..::---.---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU A ANTES THAT THE SYSTEM WILL FUNCTION SATISFACTORY. // DATE........................................................................._...... Inspector......15..�...`.--/0•G rn-•------............................. THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH ✓... .l iar..................O F...0 " r r ~, "�' ............................... No...' ...... FEE.. ................ Permission is hereby granted -- ---- to Con tr , )..or R,Ye� i ) p�-11ndividt�al Sewage Disposal S steni' I at No.........c .�'` ...... `� �. f t� Y Street / as shown on the application for �Iposal Works Construction rmit `.. . . ....... Dated.../. '.. -- --.----•------------------------ H r. DATE....................................................................... Board of ealth......,.. FORM 1255 HOBBS &'WARREN. -INC.. PUBLISHERS ; r u.Ya s LEGEND EXISTING S.A.S.(APPROX:) Benchmark Set TO BE ABANDONED t 78 PROPOSED CONTOUR PK Nail Set t Oct Rd EL.=100.00 (Assumed) 79 PROPOSED SPOT GRADE N. Pr S. Pre 0�3 6o �d NO TT/NGHAM DRl VE 7-r,, EXISTING CONTOUR o2 re TEST PIT W EXISTING WATER SERVICE Mer deh O� 1A Edge o f (�e vorr1 e:n l L , (n �_...1Ci �O;j...c? fA .. -� G EXISTING GAS SERVICE o R emarY CD `o erhora Cr \9ro -el0 ' Y` � , r — �' OVERHEAD WIRES �o N 1 -ram O.H. W. oUno° LOCUS a EXISTING PIT(FOUND) � � [ CONTRACTOR SHALL FILL \ REMOVE LAMP POST WITH SAND SLEEVE SEWER VENTQ LOCUS MAP N.T.S. 10' EACH SIDE I OF CROSSING z '-13.2'-f{ �Dc I . k _ f r t r °f7 QG GENERAL NOTES: 3 ...r i .. ♦g I�y. .,� 'r ..r .7 A { it N 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ,a �.�TP-2 -- N I• I BOARD OF HEALTH AND THE DESIGN ENGINEER. ;.+ O G-) c„i TP—,�li ;. I f,,---• -L(n � I �^gym � may, 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS _ • �{ 1 i O < �' OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE Q LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: EXISTING TANK 1) 310 CMR 15.405(1)(b) CONTENTS OF LOCAL UPGRADE APPROVAL: INV.(OUT) EL.=99.65f �w A 1' variance to maximum cover requirement of 3', for 4' of maximum cover. S.A.S. shall have H-20 units and be vented. 10 10-�I ti c� c P�r,-.4 �;•,�,,tiJ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR ! ;0,3 - •, t1 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. G7 i ✓�. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING O FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE'DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. Z :! /�i % i' /i/ / V p 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. ' / �EX/STING �/� / �(# ) / , � 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF . HOUSE 300 / // nr ly, THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF tir,,,Q; nl HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. TOF—7 03.96, 7. WATER SUPPLY PROVIDED BY TOWN WATER. ,!�' (Assumed) V / i / �; ! / /// ` �j! S. THERE ARE NO ABUTTING WELLS LOCATED WITHIN 150' OF THE S.A.S. �v�y 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. m'camw.+msmumm,o.�tn®.++.twmmm + ^+napw5lwnrFrov„�aiea� uimam uuz�iuwwxiuAws:muiwr 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY Sun THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING •,;__ „>r!~'C t"Jc "J CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. Lot 22 AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). 15,000f S.F. 12. CONTRACTOR SHALL EVALUATE STUCTURAL INTEGRITY OF EXISTING 0.34t AC. SEPTIC TANK PRIOR TO CONSTRUCTION. A,/a� 79 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY lV� / I AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. Parcel 41 PLAN REVISION 125.61' uF yqs� 2/8/07 — MOVE S.A.S. TO 20 FT. OFF CELLAR WALL -F-- S 39 05'20" Wq�yG PETER E T. PROPOSED SEPTIC SYSTEM UPGRADE CIVIL 300 NOTTINGHAM DRIVE, CENTERVILLE, MA No. 35109 p Prepared for: Said Zarthor, 300 Nottingham Dr., Centerville, MA 02632 C/SZE�� �� 'O� E � Engineering by: Surveying by: SCALE DRAWN JOB. N0. t, EngineeringiWorkv Terry A. Warner PIS 1"=20' P.T.M. 115-07 r� 12 West Crossfield Road 22 Long Rood DATE V Forestdale, MA 02644 Harwich, MA 02645 CHECKED SHEET NO. v (508) 477-5313 (508) 432-8309 2/6/07 P.T.M. 1 Of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED T.O.F ; F.G. EL: 102.5(MAX.) FINISH GRADE SHALL NOT BE < EL.98.5 (EXISTING) } VENT FOR RIMETERDISTANCE OF OFS A.S.AROUND THE EXISTING F.G. EL: 103.0t(EXISTING) I F•G. EL: 102.5t f MAINTAIN 2% MIN SLOPE OVER S.A.S. 4' SCH �4O PVC PERFORATED PIPE WITH SCREW C SET TO WITHIN 3" OF FINISH INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D-BOX TO 9-500 GALLON LEACHING CHAMB05 GRADE TSERVE AS INSPECTION PORT. TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES INSTALL RISER OVER CHAMBER prn SHOWN ON PLAN AND SET COVER L =40' L=4' WITHIN 6' OF FINISH GRADE 4" SCH 40 PVC 4" SCH 40 PVC 2" LAYER OF 1/8" TO 1/2" i0.1 6 ®6 4ti ®B DOUBLE WASHED STONE EXISTING 14 ( ) S ^ ® S= 1% MIN. ®aa 6®® 1000 GALLON ® = 1% (MIN.) ®a B®11 (OR APPROVED FILTER FABRIC) e SEPTIC TANK J: INV=99.17 INV.=99.00 2' EFF, DEPTH Em 0063® . (SEE NOTE 12 —SHEET 1) 3/4"-1 1/2" EXISTING o cA aWF1 INV.=99.65t D—BOX 4' S.2' 4' STTONEE WASHED . ...... ... EFFECTIVE WIDTH = 13.2' NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING INV.=98.00 PIPE INVERTS PRIOR TO CONSTRUCTION. 2) D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE TOP CONC. ELEV.=99.0 —BREAKOUT ELEV.=98.5 ON A MECHANICALLY COMPACTED SIX INCH CRUSHED INV. ELEV.=98.00 ®®aaa STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) 3) INSTALL INLET & OUTLET TEES AS NEEDED. BOTTOM ELEV.=98.00 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE. 3' 2 x 8.5' = 17.0'-1 3' 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23A' T.P. EXCAVATION OR G.W. SEPTIC SYSTEM PROFILE NO G.W. ENCOUNTERED LEACHING SYSTEM SECTION BOTTOM OF TP EL: 89.7 N.T.S. NOTE: SOILS CONSISTANT WITH SOIL LOG SHALL BE VERIFIED AT TIME OF INSTALLATION. (3) 5" DIA.OUTLETS SOIL LOG DATE: FEBRUARY 5, 2007 DESIGN CRITERIA 1 » SOIL EVALUATOR: PETER T. MCENTEE P.E. NUMBER OF BEDROOMS: 3 BEDROOMS 15.5" - El 6» WITNESS: DON DESMARAIS SOIL TYPE: CLASS 1 6 (HEALTH AGENT) DESIGN PERCOLATION RATE: 2 MINJIN. 2" REFERENCE N0 P-1 1,633 DAILY FLOW: 330 G.P.D. . H-10 LOADING DESIGN FLOW: 330 G.P.D D—BOX Elev. TP- 1 Depth EieV. TP-2 Depth GARBAGE GRINDER: NO KL8 101.5 0„ 101.6 0'• LEACHING AREA REQUIRED: 330 = 445.9 S.F. FILL FILL .74 100.5 A 12" 101.4 A 14" EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (ESTIMATED) E3E3EOE3 0 ®®®® ®®®®®®®®®®® 37" SANDY LOAM SANDY LOAM a EMIE3®®EI®®®®®® 10YR 3/3 10YR 3/3 USE 2-500 GALLON LEACHING CHAMBERS IN-SERIES N ®R3®®®E3®®®®® 99.0 20„ B 99.0 e 22" SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. 102" SANDY LOAM SANDY LOAM BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F. 10YR 5/8 10YR 5/8 TOTAL AREA: 448.4 S.F. 4' KNOCKOUT 98.2 C 42" 4 " 98.1 C 42" DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. 20" OiA. COVER PERC • KwocKouT O/a• KNOCKOUT 62• 9 54 I PROPOSED SEPTIC SYSTEM UPGRADE M—C SAND M—C SAND 4• KNOCKOUT 10YR 5/4 ) 1OYR 5/4 300 NOTTINGHAM DRIVE, CENTERVILLE, MA 10% GRAVEL 10% GRAVEL Prepared for: Said Zarthar, 300 Nottingham Dr., Centerville, MA 02632 500 GALLON CAPACITY, H-20 LOADING 89.7 142" 89.8 142" Engineering by: Surveying by: SCALE DRAWN JOB. NO. EngineeringW'orb Terry A. Warner PLS NTS P.T.M. 115--07 CHAMBERS NO GROUNDWATER OBSERVED 12 West Crossfield Road 22 Long Road — N,r. PERC RATE <2 MIN/IN- ("C" HORIZON) Forestdale,'MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 2/6/07 P.T.M. 2 of 2