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Home My WebLink About0480 NOTTINGHAM DRIVE - Health 480 Nottingham Drive A= 041-032 S M E A D 1 No.2-IU OR UPC 1zsu smssdoom s Ysdt In UM s00* r I IF ORMW oleo ?n(C a 3�1 �.aiL �s�.. 21 ?O t 3 C 7,777777 OA SlrA4 � f y OIL } F, 1iy. of�rays, Town of Barnstable • t + HARN3fABLE, Board of Health lFD MP't A 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Junichi Sawayanagi Paul Canniff,D.M.D. Wayne Miller,M.D. November 20, 2012 Mr. Donald Pires 480 Nottingham Drive Centerville, MA 02632 RE 480 Noom am Drive, Ceriterv111e 147 O15 :_. Dear Mr. Pires, The order from the Health Agent dated March 30, 2012 to repair a failed septic system at the 480 Nottingham Drive is lifted. The septic system originally "failed" during an inspection conducted by Mark Polselli on August 18, 2011. He noted on his inspection report that the septic tank was leaking at the seam and the leaching pit was in `hydraulic failure' with a note that he observed staining at the invert. I Six months later,the system "conditionally passed" during an inspection conducted by Michael Kellett, a DEP certified septic system inspector, on February 12, 2012. His inspection report noted that `there may be a slight leak in the septic tank' and he further noted that the leaching pit `was dry and had a stain line twenty inches from the bottom.' Eight months after that, on October 16, 2012, the septic system "passed" an inspection conducted by Matthew Childs, a DEP certified septic system inspector license#514386. His report noted that there were no signs of leakage from the septic tank. The leaching pit contained only six inches of water with the stain line at two feet. Based upon the information presented,the Board is of the opinion that although this system is approximately thirty-three years old and although there is no guarantee in regards to the system's.performance in.the future, at this time it has been proven that this septic system is not a source of pollution nor a public health nuisance to the occupants or to the n ighbors. Therefore,the original order dated March 30, 2012 is lifted. Sinc e y yours, Wayne ler, M.D., Chairman QAVariances 013\PiresFailedPassedSystem480Nottingh riveDec2012.doc eat Crocker, Sharon From: Crocker, Sharon Sent: Wednesday, November 14, 2012 3:57 PM To: 'djpires651 @aol.com' Subject: 480 Nottingham Dr, Centerville - Board of Health /JO-Y RE: Board of Health Meeting November 13, 2012 Hello Donald, The Board of Health voted to continue your item to our December 11, 2012 meeting as they had some questions regarding your septic and would like to have you present to answer them prior to the vote. The meeting will be at: Town of Barnstable Main Town Hall 367 Main Street, 2nd FI. "Hearing Room" Hyannis, MA Date: Tues- December 11, 2012. Time: 3:00 pm -apprx 5:30 pm. An agenda should be available Thursday, December 6. Any questions,just give us a call at 508-862-4644. Thank you. Sharon Crocker Admin. Assistant 1 t i o Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is Centerville MA 02632 02/12/12 required for every City/Town State Zip Code Date of inspection page. 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 computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Hame of Inspector key. Aardvark Environmental Inspections Company Name P.O.Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385 7608 SI 3742 Telephone Number Ucense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.3�40 of Title 5(310 CMR 15.000).The system: C3 ,r, :r- G � 2 ❑ Passes ® Conditionally Passes ❑ Fai "� 4 C3 ❑ Needs Further Evaluation by the Local Approving Authority ` L E5' .� 02/15/12 Inspect rs Signature Date tom' lJ1 The system inspector shall submit a copy of this inspe of�r ort 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 t5ins•11/10 ' t ` 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. City/Town state Zip Code Date of Inspection B. Certification (cant.) Inspection Summary:Check A,B,C,D or E 1 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 ortank 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): The tank may have a slight leak at the seam since the liquid level was was low/7"-8"above seam. There was however staining at the outlet invert which would indicate that the leak was small and should seat itself,nor would it have even been apparent under normal flow.This is NOT a metal tank. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts u Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 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 FIND(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: ❑ pay or Cesspool is within 50 feet of a surface water P ❑ Cesspool or privy is within 50 feet of a bordering vegetated:wetland or a salt marsh 15ins•11i10 Title 5Offycial Inspection Form:Subsudace sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 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 asses if the well water analysis, performed at a DEP certified laboratory,for fecal Y P Y � p ry, 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 fort. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth Not for Voluntary Assessments 04 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Cityrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form & Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Cityfrown 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 (f 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 I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 08/11 Date CommemialRndustrial 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Citylrown 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) (f 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 VA 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 s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (f known)and source of information: 09/15/80 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.0 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: 2.5 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 j Sludge depth: 4" t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" 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 with tees in place and liquid 16"below outlet invert.There may be a slight leak at the seam. 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/to Idle 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 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is Centerville MA 02632 02/12/12 required for every ` page. Citylrown 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•11/10 Title 5 Official Inspection Form: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 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Cityrrown 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): rp Y ( ) � P If SAS not located,explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions:. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): This system has a 6'x6'precast pit surrounded by 1'of stone.The pit was dry with a cut in the sand from the liquid splashing into the pit.There was a stain line 20"up from the bottom with some indication that the water may have risen a couple of feet higher on occation. 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 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Cityfrown State Zip Code Date of inspection D. System Information (cunt.) 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.): I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 77 17 3` b3 75 t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,H 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 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: 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 I Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Nottingham Drive Property Address Donald Pires Owner Owner's Name information is required for every Centerville MA 02632 02/12/12 page. Citylrown 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 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/1512000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: 480 Nottingham Drive Property Address Donald Pires Owner's Name same Owner's Address Centerville MA 02632 City/Town State Zip Code Date of Inspection: 10/16/12Date 2. Inspector: Matthew L. Childs Name of Inspector same Company.Name 4 Orchid Ln. Company Address W. Yarmouth MA 02673 City/Town State Zip Code 508-989-1479 Telephone Number Certification Statement: 1 certify that I have personally inspected the sewage disposal system at this add and thai-lie information reported below is true, accurate and complete as of the time of the ir)sp ction. Thginspiltion was performed based on my training and experience in the proper function and rriai tenancf on use sewage disposal systems. I am a DEP approved system inspector pursuant to? lection 1.5.340 0 . Title 5(310 CMR 15.000).The system: " 10 �:W ® Passes ❑ Conditionally Passes ❑ Faily� z c ❑ Needs Further Evaluation by the Local Approving Authority �-r► 10/16/12 spector'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. pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'M A. Certification (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection 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: 2 Previous inspections showed conditional pass for the reason of a leaking septic tank and hydraulic failure of the SAS. Septic tank was at operating level and SAS had 6" of water and stain lines at 2' at the time of this inspection. Further requirements per Barnstable BOH may be necessary. 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: N/A pires.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 Cityrrown State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: N/A ❑ The system required pumping more than-4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: r N/A 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 pires.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 E Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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: N/A **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: N/A pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State ZipCode Donald Pires 10/16/12 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or. obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No El ® 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. pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts u Title 5 Official Inspection Form Not for Voluntary Assessments c^ Subsurface Sewage Disposal System Form M 5ray`s i A. Certification (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form '4M B. Checklist 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection 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(3)(b)] pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage.Disposal System Form C. System Information 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd. Number of current residents: 1 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)): N/A Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Last date of occupancy/use: N/A Date Other(describe): N/A pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: owner scheduled pumping after inspection. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 9/15/80 per BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name _ Date of Inspection Building Sewer(locate on site plan): Depth below grade: 3 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.): All in working order at time of inspection. Septic Tank(locate on site plan): Depth below grade: 2.5'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 ❑ Yes ❑ No certificate) Dimensions: 8'x5'x5' outside 1000 gal. Sludge depth: .4 Distance from top of sludge to bottom of outlet tee or baffle 2.8 Scum thickness 2 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 .8' How were dimensions determined? sludge judge pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iv^M Subsurface Sewage Disposal System Form C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection 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 shows no sign of leakage and pumping was scheduled by owner upon completion of inspection. Grease Trap (locate on site plan): Depth below grade: N/Afeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): . N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'wM C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 Cityrrown State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A Capacity: N/A gallons Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.0' 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.): D-box is level with no leakage or solids carryover at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments i4,M SV Subsurface Sewage Disposal System Form C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1 6'x6' precast pit lined with 1' of stone had 6" of water and stain lines at 2'. Although SAS is not in failure it is 30+years old and this report does not guarantee the systems performance in the future under the same or different conditions of use. pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes El No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form '4M C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection 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. garde #480 A a-63' B-2-17' O m pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments G^M Subsurface Sewage Disposal System Form C. System Information (cont.) 480 Nottingham Drive Property Address Centerville MA 02632 City/Town State Zip Code Donald Pires 10/16/12 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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 groundwater greater than 20' at this site. pires.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. Company Name P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/27/12 Inspector's Signature Date The system inspectors submit a copy of this inspection report to the Approving Authority(Board of Health or DEP),w In 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. U IIV t5ins•11/10 Title 5 Official Inspectio F r . bsurface Sewage Disposal ystem•Page 1 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. Cityfrown State Zip Code Date of Inspection B. Certification 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: tank in good condition with concrete Baffles in place Dbox in good condition leach pit is dry has staining 6" up from bottom no signs of staining above that point. 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (corl ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑'Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. Cityfrown 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. City/Town 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: none 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): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 L_ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1980 town file Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 15+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.5 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: 3" l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21" Scum thickness Y Distance from top of scum to top of outlet tee or baffle 51' Distance from bottom of scum to bottom of outlet tee or baffle 23" How were dimensions determined? sludge judge tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 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 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.): level no cracks or leaks 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: dug up staining 6" up from bottom of leach pit t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I - . Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 l . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 36 �� t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i • Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 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: 15+ 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: topo maps You must describe how you established the high ground water elevation: t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 480 Nottingham Drive Property Address Owner Owner's Name information is required for every Barnstable Ma 11/27/12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E 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 l �� a - m0.5- .. a; zo .�. ` ro arnstable Barnstable °p TFIE T°�y Regulatory Services Department I it I BARNSTABLE, m MASS. Public Health Division rf°M"�a 200 Main Street, Hyannis MA 02601 007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3524 5764 March 30 2012 Mr. Donald Pires 480 Nottingham Drive Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located at 480 Nottingham Drive, Centerville, MA was last inspected on 2/12/2012, by Michael Kellett, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • SAS is in Hydraulic overload • Septic tank is leaking—It needs to be either sealed or replaced You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. Zom 7sMcKean, OF THE BOARD OF HEALTH R.S. C. Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\480 Nottingham Dr.Cent.doc2 `S t!i Town of Barnstable Barnstable PROF THE TO�� regulatory Services Department i�cac j + BARNSCABLE. yAss. m Public Health Division ATFo Mrt'' 200 Main Street, Hyannis MA 02601 2�07 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3524 5430 November 8, 2011 Sandra Kash % Fannie Mae A/K/A Federal Nat'l Mgt Dallas, TX 75265-0043 AUL RE: 480 Nottingham Drive, Map 147—Parcel 015 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 480 Nottingham Drive, Centerville, MA was last inspected on 8/18/2011, by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Fails"under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: SAS is in Hydraulic overload • Septic tank is leaking—It needs to be either sealed or replaced You are ordered to repair or replace the septic system within sixty (60) clays from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action: PER ORDER OF THE BOARD OF HEALTH i:L✓� as McKean, HO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\480 Nottingham Dr.,Cent.doc Postal m r. (Domestic Mail Only; Provided) For delivery information visit our website at www.usps.cornD t.rl m Postage $ p p Certified Fee i ostmark p Return Receipt Fee ( Here (Endorsement Required] AFR— Cd�2 p Restricled Delivery Fee r-7 (Endorsement Required) co p Total Postage&Fees L7 r Mr. Donald Pires 480 Nottingham Drive Centerville, MA 02632 Certified Mail Provides: s� • A mailing receipt iasjwu)Zooz aunt'008E uuod Sd O A unique identifier4or your Ailpiece •.A record of delivery kept by the Postal Service for two years Important Reminders: e Certified Mail may ONLY be combined with First-Class Mello or Priority Mail®. ■ Certiffed Mail is not available for any class of international mail. • NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. 19 For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811�to the article and add applicable postage to cover the fee.Endorse mailpiece'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. a For.an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". • H a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. -IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. COMPLETE •N COMPLETE THIS SECTIONON ■ Complete items 1;2,and 3.Also complete A S nature item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we Can return the card to you. B. ecei d (Printed Name) C. Datv of livery n Attach this card to the back of the mailpiece, � 1 Article Addressed to: L I or on the front if space permits. D. Is delivery address different from item 1? s . If YES,enter delivery address below: ❑ o Mr. Donald Pires I M r I 480 Nottingham Drive - Centerville, MA 02632 y 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ((Transfer from service labeq _ i;?�0 6 0 81.0 10000 3524 5737 e PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATEScwy�-p� u e 4M; * '<,�.�we,n ?l:�.a' ��','4`ra'.�: ��;�' .by ✓ n .. �... aid An i`1-QJw'Ka.f...d^�t' pp[�� :lti:R'.ib4n✓L.t::. °,.;� .c' NI`T.FT• •':a'y"L'f.., tt p -y {, .rY';F. OwOw..Y•`s:..o,.;i,:ib•:.4,'f+ •Y,,:`,t'`7'. :.€G. �:YN Yiv • Sender: Please print your name, address, and ZIP+4 in this box • R Town of Barnstable Public Health Division 200 Main Street I Hyannis, MA 02601 :.i..•%..i:�. 1111111j1111:11ttflH fill iIJ1111111l1lilNii fill Iilll'?!!-111111 No......-- _ Fms.. . ... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Applira#ion for Di-spniiFal Worko Ton,otrnr#inn Urrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ..... tip �s�e � - �oT 38 ................ Location-Address 6:� or Lot No. ----•------ ' ��- , ..I?�v.._.iN................................ l ®-rr�N HftM D,c'............................... Owner61 Address Ins aller Address Type of Building Size Lot_/S ......Sq. feet a Dwelling—No. of Bedrooms................................. Other Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons------------_............... Showers ( ) — Cafeteria ( ) w Other fixtures Q ---------------------------- ------------- --------------- W Design Flow.........� .........................gallons per person per day. Total dai'I flow..........__.-3._...®................gallons. WSeptic Tank—Liquid capacity/190-.[?_-gallons Length...._..7....... Width..... Diameter................ Depth.._..1;t- ........ x Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--_-_-_�---------- Diameter--------<5........ Depth below inlet.......4..`...... Total leaching area..Z.e�.....sq. ft. z Other Distribution box (x) Dosing tank ( ) Percolation Test Results Performed by..... ...... w--- ...... Date.......1 L_,. ...... .BD. aTest Pit No. l..C.z._..minutes per inch Depth of Test Pit.../_44........ Depth to ground water.Na.7�.EN" Test Pit No. 2..�.z....minutes per inch Depth of Test Pit__/... ..r.... Depth to ground water _A/ -------------------------------- a_._...._...... O Description of Soil 4 y L"�9 y' `Sv13so�L--------�---------1 V.1...�---�-.......---......... U .............. ...........................-E-------------------------------- W ------------------------------------------------•--------------------------------------------------•----------------------------------------------------•---------------------------------..........---- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ----------------------------•-------•------------------------------------------•----................--------...-------------------------------------------------•--- .................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i?`=LEE 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board-of health. Sigd......... ----- ------------------•--------------._...---------------------------- ................................ Date Application Approved By .. ..... ...... .. . .� .....---------,=........ .7" 9�t _ ` Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------.............. --------•-------------------•-----•---------------••--------------------------------------------...... •----------------------..._..-----------------------•------------------------------.......... Date Permit No.. ... Issued--.<�'� ----•---- ------ Date No........ i...... .............................. THE COMMONWEALTH OF MASSACHUSETTS �— BOARD OF HEALTH ..............i.✓.✓...................O F.........L✓ ,2 cJ-S,: 1 _45.4--4.: --------......_................. ApPrFatiun for Uiupuual Workfi Tunitrnrtiun ranfit Application is:hereby made for a Permit to Construct ()e) or Repair ( ) an Individual Sewage Disposal System at: ....... _ Location-Address or Lot No. . z� ,_ __l�r�oyinJ ..../l.�oTT/ ... G> Owner Address CENT=/eV L(l a ............. . -- . •............................................. •-••.•...•••----•••••-•.---•-•.----•-..--•..---.-----•........................................... Installer Address d Type of Building Size Lot_�5.. f....3........Sq. feet Dwelling—No. of Bedrooms.............. 3....__........_....__..__Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures .................................. W Design Flow......... - .........................gallons per person per day. Total dail flow_............3--3-.0.....•.......•._gallons. ar W Septic Tank—Liquid capacity/.!?P .gallons Length-------.__'__. Width-___-_-•__I-1___. Diameter________________ Depth....-......... x Disposal Trench- No..................... Width_.C.�._._._...._...... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........1........... Diameter-------cf........ Depth below inlet.......?.......... Total leaching area..Z.9°.....sq. ft. Z Other Distribution box (X) Dosing tank ( ) '-' Percolation Test Results Performed by...__G ..-.L `J.._ -._. G........ a Test Pt No. 1__C.Z__..minutes per inch Depth of Test Pit._�` ��_.___. Depth to ground water_tio_?___ f✓' tTA Test Pit No. 2..C.z....minutes per inch Depth of Test Pit_./_`.F.g__`'....Depth to ground waterw�^�T�2E� 1:4 -4/ .............................................•---•-•---••----••-•-•--•-•................._..•-----............•---............•.... .-•------------ D Description of Soil.... •- -•----Z--`'•f••1 Lo `-.............. `-/4'viG_- 2 4 /V S! '............................................ 5' ,c /�U ...................................................'t - --------------------------------------------------------------------------------------•--•----•----------------.......---------------------- W ---•----------------.............................. --------------------------------------------------------------------------------------------------------------------------------------•---•-----... 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 TIT TT' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. f Sign A .....---•-•----••• _ Tat Application Approved BY---------- ------PP PP =- �il.Jl��'rre'r�•-- ...---�---------------------- -- -Wf--'---- ?,Da ----�-»� Date Application Disapproved for the following reasons--------------------------------- ---------------------•----................................................... Date Permit No...................................................=..... Issued------•-- '.... -`�A-•.. .................. Date _ f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............* .......O F............Wjj�............................................. !!! err ifirtt r of loutpliFanrr THIS 1 T C TIFY, That the Individual Sewage Disposa System constructed ( or Repaired ( ) .., by....... . .,_.. '. .. ................... Install has een /with the application forlled in Dispo alcWorkseConstruction Permit No.Q ;� State Sanitary Cgde a des ri}�ied in the provisions ICJ T - - -- ------------ dated._ .--� -- �-- -----' THE ISSUANCE OF THIS CERTIFICATE SHAL BE CONSTRU ® AS_A GUARANTEE THAT THE SYSTEM 1AlILL,,�,�JNCT/ION SATI A ORY. ;� - -� DATE - ` F�� Insgeetor. i THE COMMONWEALTH OF MASSACHUSETTS BOARD O . HEAL �� .. ............... ...�c l '1.......0 F......... l '�G� �'� .................... No.- ..S ._ FEE.. Q.... .... �iu�tvlu�t � ��riun .rrntt� Permission is her y granted..:..__.._ ..�_.. ._.__.. .............. to Construes,,( or Re it ( ) ant,Indivi`u ra e'.isp 7 at No...... rf'. "* f� •e�r5, ' < ... r . ,�.•: Street ... !� - as shown on the application for Disposal Works.Construction Per --. - Dated.......................................... ..... 7 ................. ,1 ........... j •••.. '......•••... w Board of H :t. DATE----•-......•----••-----•. ••-•••.......................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS L O CATION -S E WA G E PERMIT JNO• Gv�- 3�l /ti/D 7 7"s/y 6r-111P /- O/Ipv vim_ VILLAGE (nFA171:70f �c L INSTA LLER'S N ,A/ME i ADDRESS /-/V Crr� S 3UILDER OR OWNER O ,PeO C IAI DATE PERMIT ISSUED �_?o DATE COMPLIANCE ISSUED � _ /s- ��x eg a 02.4 i SuBsot� c�t35o t1— A 00. 3 14" 20. 4 ?�! s 19' 7 20 • 0 20. ZMED 20 6 /82. ,00 ' 2/ o 2l 2 G7 .S A A1 D 151 O 03 N w/ LOT �6 , t 6eHveL E/ 2z•4 P,eoy; VeoP. •�` .r � LDT /00'70 BLD 6 . 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