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HomeMy WebLinkAbout0007 SOUTHPORT LANE - Health 7 Sou"thport Larie Hyaririis ' kt 414 I I II i, ^-� TOWN OF BARNSTABLE LOCATION /� �1�� i � SEWAGE # D:? VILLAGE S ASSESSOR'S MAP & LOT 111STALLER'S NAME&PHONE NO. �f. �' iUC® 7Sr�oZ S66 SEPTIC TANK CAPACITY 6'X(STI�i l�`V -x LEACHING FACILITY: (type) 3�Sg�( ���t�c-Il S (size) NO.OF BEDROOMS .3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: ;�S^' 62 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching..facility) Feet Furnished by o G � IV `-_ O-1 1- - O_ a"wN ,a -- d No. ( 3,= - 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprtcation for Migooal *p5tem Construction Vermtt Application for a Permit to Construct( )Repair( L4epgrade( )Abandon( ) ❑Complete System D Individual Components Location Address or Lot No. 7 Soo A dT+ �,q Owner's Name,A dres and T 1.No. Assessor's Map/Parcel _ I's—o,T' Installer's Name,Addres t'I1i4AN0D Designer's Name,Add s and Tel.No. 350 Main Street Ir(f/eF rn W. Yarmouth, MA 02673 7SY- 5'87- oa 73 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers.( ) Cafeteria( ) Other Fixtures L, Design Flow gallons per day. Calculated daily flow 3 7 b gallons. Plan Date 73 Number of sheets ? Revision Date vtl)14 Title /tLe—+ -r_ Size of Septic Tank lel l ;-19 Type of/S-.A.S. Description of Soil G`��f AGyw/ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the En onmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this d 9f Health. r Signed Date 1O Application Approved by Date /' 0 3 Application Disapproved for the following reasons Permit No. -®d — a' Date Issued G 3 No aob i 'Fee THE COMMONWEALTH-OF MASSACHUSE Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for �ig;pooal bpgten `Congtruction Pitmit Na t, Application for a Permit to Construct( )Repair( 1—)epgrade( )Abandon( ) ❑Complete System ❑Individual.Components l° k Location Address or Lot No. '� SOU��►�U f t W f ! Owner''s Name,Address and Tel.No. grA,)n Assessor's Map/parcel { Installer's Name,Address, T Designer's Name,Add s and Tel.No. aA W CANCO �y n 350 Main Street W. Yarmouth Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons'Y' li, Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 4 gallons. Plan Date /3 Number of sheets / Revision Date A.))Al A Title Size of Septic Tank /D n exit Type of&,.k . r Description of Soil ? . /0®r AAAJ I Nature of Repairs or Alterations(Answer when applicable) IDe,f? (�i✓, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the KHeaIth. ' nmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this o d j ..• :; Signed Date 7 � #. ""7/i8 Application Approved by Date 00 Application Disapproved for the following reasons Permit No. o1-QO 3 -- 3f` Date Issued '2 L G -------------------------- a t k THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( r-.),��raded( ) Abandoned`(' b at 77 J f IA., W AIVA has been construe ed 'n accordance with the provisions of Title and the for Disposal System Construction Permit No.T o03-37-9 dated 9117 1 A 3 Installer Designer i ,-'The issuance oft .s pe I shall not be construed as a guarantee that the system-w"A 4•c Date � 2 , 1)3 Inspector _ r --------------------------------------- No. -0©•3 3 Fee � U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS %Iigpogaf *pztem Construction Permit Permission is hereby granted to onstruct( )Repair Grade( )Aba don( ) System located at T� 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:Construction must be completed within three years of the d of�'— (3�Dater ! O Approved 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments m �M 7 Southport Lane Property Address �] V Onelia McNamara Owner Owner's Name information is / required for every Hyannis ✓ MA 02601 9-6-16 page. City/Town State Zip Code Date of Inspection .;a 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 ng out forms A. General Information ����""""'+►����, on l the computer, 5[ ""O OF Mgssq use only the tab 1. Inspector: ��o�' ' . •••'C�G�% key to move your =�: JAMES .P cursor-do not James D.Sears 'o use the return =�, SEARS ;o ke Name of Inspector Y� , �y� Jim The Inspector Man "�—\I Company Name4 5 I N SP� � t P.O.Box 784 Company Address few West Yarmouth MA 02673 City/Town State Zip Code 508-364-4398 S1623 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 9-6-16 nspector'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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional,office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 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: The system is a 1000 Gal. Tank D Box and three chamber's. 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): 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 G, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 page. Cityrrown 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. El 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 REIRM is less than 6" below invert or available volume is less than '/day flow t5ins.doc-rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a y 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name - requir required is Hyannis MA 02601 9-6-16 required for every y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of,the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D.,System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is H annis MA 02601 9-6-16 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: y The system is a 1000 Gal. Tank D Box and three chamber's. Number of current residents: 4 Does residence.have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): na Detail: Sump pump? ❑ Yes ® No Last date of occupancy:. PresentDate 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 El 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.doc-rev.6/16 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 M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 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: NA 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2003 Permit #2003- 329 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site.plan): Depth below grade: 27" feet Material of construction: ® concrete El 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. Precast H-10 Sludge depth: 2" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 page. Cityrrown 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 1" Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and inlet cover at 27" below grade w/outlet cover at 7". In and outlet tee's. No sign of leakage or overloading. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): I 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.doc•rev.6/16 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 �M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 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 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 16"x16"-39" below grade w/cover at 2'. Box is clean and solid w/two lines out. No sign of over loading or solid carry over. 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.): * If pumps or alarms are not in working order, system is a conditional pass. ` Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins.doc•rev.6/16 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 °M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is H annis MA 02601 9-6-16 required for every y page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): Leaching is three 500 Gal. Dry well chambee's w/2:5' stone. Ck box and camera out to chambers. 12"water in chambers.Wall's are clean. No sign of over loading or solid carry over. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 TOWN OF BARNSTABLE LOCATION r Ld SEWAGE 0 3a-S VILLAGE' "A .16, S ASSESSOR'S MAP & LOT 3 �'q 1 INSTALLER' PHONE NO. 7 � '� 2-7S--,;L SEPTIC TANK CAPACITY ��Xrs7 MOO LEACHING FACILITY: (type) VL (size) NO. OF BEDROOMS— BUILDER OR OWNER , �- 3 l DATE: `7- S.. PERMITDATE. COMPLIANCE DA d3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by. + E. � I C, 35; v 03 t t� .yy O i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name ' information is Hyannis MA 02601 9-6-16 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope - ❑ Surface water ❑ Check cellar ❑ Shallow wells luo' Estimated depth to h! igh ground water: 11'-6" 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: 6-18-03 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: TH on Design Plan 6-18-03 no G.W. at 11'-T. Bottom of leaching at 6'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Southport Lane Property Address Onelia McNamara Owner Owner's Name information is required for every Hyannis MA 02601 9-6-16 page. CitylTown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION """ ' (j SEWAGE # S 3 ic� VILLAGE ASSESSOR'S MAP&LOT- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY rx�G i X--, LEACHING FACILITY: (type) 3�5 +( ni2��. 1(S (size) NO.OF BEDROOMS 3 _ a BUILDER OR OWNER PERMTTDATE: -7—l F'O 3 1 COMPLIANCE DATE: � 6 Separation Distance Between the:` Feet Maximum-Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by. Y -560 P c2 e r� 3 a ° -• -fir _ .. . t COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL POBE ION ' RECEIVE® J U N 0 4 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Addressi '� — FAILED INSPECTION Owner's Name: ( �� n�.�A Owner's Address: Date of Inspection: U (� Name of Inspecto please print PARCEL � .4 t 41- Company Name. ! C LOT ° Mailing Address: (� _) Telephone Number: ' 7 - �� ! CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails 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. . Notes and Comments-:,. ...f.. ****This is it This report only describes conditions at.the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of.use. Title 5 Inspection Form 6/15/20.00 page I Page 2 of 1 1 r; �a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Z,&!—tgw� A�4—e P , C/0412?10""14 Owner: Date of Tnspection: dC�: 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 031orgym 310 CMR 15 304,eexist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exf ltration 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 ou'or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than*4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page I of 11 . OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION,(continued) Property Address: / Owner ,Date of Inspection: C. Further Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of-Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which.will protect public health,safety and the environment:. Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within.50 feet of a bordering vegetated wetland or a salt marsh . 2. System will fail unless the Board of Health (and Public Water Supplier, if any).determines that the system is functioning in a manner that protects the public health,safety and.environment: The system has a septic tank and soil absorption system(SAS),and the SAS is within 100 feet of a. surface water supply or tributary to a surface water supply. _ The system.has a septic tank and SAS and the SAS is within a.Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private.water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a. private water supply well"..Method used to.determine distance "This system passes if the well water analysis,performed at a DEP certified.laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 ,Page 4 of 11 OFFICIAL INSPECTION FORM—:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �✓L �i Owner: Date of Inspection: 0,3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Ye No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool V. Discharge or ponding of effluent to the.surface of the ground.or surface waters due to an overloaded or J clogged SAS or cesspool r/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ,! Liquid depth in cesspool is less than 6"below invert or available volume is less than�/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply. _ � Any portion of a cesspool or privy is within a Zone 1 of apublic well. VAny 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 pp are triggered. A copy of the analysis must be attached to this form.] (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,the efore 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 mustserve a facility with a design flow of 10;000 gpd to 15,000 gPa- 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—I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section Ethe system is considered a significant threat, or answered "yes" in Section D above the large system has.failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall.upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 F: Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL-SYSTEM INSPECTION FORM "PART B. CHECKLIST Property.Address: Owner . i9h-A_ Date of Inspection: Zj2tj a'z �00 Check if the following have been done. You must.indicate`yes"or"no"as to each of the following: Yes -o Pumping.information was provided by the owner,occupant,or Board of Health ere.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 t� 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 — LZExisting 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)J 5 Page 6 of 1 I ' OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /q Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . Number of bedrooms(actual): DESIGN"flow based on 310 CMR 15.203 (for example: 110-pd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no). Lw Is laundry on a separate sewage system(yes or no if yes separate inspection required] Laundry system inspected(yes or n Seasonal use: (yes or no): Water meter readings, i available(last 2 years usage(gpd)): l"" z Sump pump(yes or no Last date of occupancy: P yzd/c, COMMERCIALIINDUSTRIALi_� Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): ' GENERAL INFORMATION Pumping Records Source of information:�aj ZQ� 1") ?Y<am Was system pumped as part of the i spection(ye r no� If yes,volume pumped: gallons--How was quantity pumped determined? Reason Tor pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval ether•(describe). ' C ape Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no)VjL"`� 6 Page T of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C SYSTEM-INFORMATION(continued)- Property Address: Owner: '&"q4 a "'A Date of Inspection: BUILDING SEWER(locate on site plan)/,XO— Depth below grade: Materials of construction: cast iron . 40 PVC other(explain) Distance from private water supply well or suction line: r Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) &A a / .: t ; Depth below srad 01 Material of construction: ✓concrete_metal fiberglass_polyethylene other(explain). If tank is metal list'ace: tee._ Is aQse confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: S' X Sludge depth:�p 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 ba fle: iG How were dimensions determined: � �eCa weh­ Comments(on pumping recommendations, let and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert evidence of leakage,a .): >t GREASE TRAM/ locate on site plan) Depth below grade:_ Material of construction:—concrete, metal.—fiberglass_polyethylene_other (explain): Dimensions: Scum.thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 . Page 8 of I I OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /J! Owner: Date of Inspection: 3 TIGHT or HOLDING TANk-14 (tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PUMP CHAMBER: 1--(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address,: AIA Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): L(locate on site plan,excavation not required) If SAS not located explain why: T naching pits,number:L 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, jto 'o e . a . al- 02te ,Piny CESSPOOLS/jj.(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�lkL�(Iocate on site plan) Materials of construction:. Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9. . Page 10 of 1 I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ® i Owner: 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 jj building. Ir It 0 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: inr Date of Inspection: C�(.� j 7. HOC SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water 1� feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained-from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with.local Board of Health-explain: Checked A.ith.local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: /? � k7107 l i i 11. Permit Number: Date: Completed by:. HIGH GROUND-WATER LEVEL COMPUTATION Site Location:.. /,17"'�f (�/,. Lot No. Owner:-- � boarie Address.: Contractor. !'� � rh5/r Address: 7, �G Notes: /1� 15 STEP 1 Measure depth to water'table to nearest 1/10 ft. ................................... ........... . Z� ......................... . ...... Date-�� month/day/Year STEP 2 Using Water-Level Range Zone and.Index Well'Map locate site and.determine: OAppropriate index well :... .:......................... � I Water-level range zone ........... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well .......::.. � � Z Z ................ month/yee ar STE° 4. Using Table of.Water-Ievel..Adjustments. for index well (STEP 2A), current depth to water level for index well (STEP 3).; and water-level zone (STEP 2B) determine water-level adjustment-.................. „•, ................................................ STEP 5 . Estimate depth to high water by subtracting the water level adjustment (STEP 4). from measured depth to water level at site (STEP 1) .................. . ..............:......•. Figure 13.--Reproducible computatim form. 15 r� � E G t� f w N S; h-esS_ TOWN OF BARNSTABLE LOCATION Sut 1 Lt�oh�- SEWAGE #'OI' F —5-03 �LAG a 7 rl I s ASSESSOR'S MAP & LOT, INSTALLER'S NAME&PHONE NO�Ve r-o eohak,1- ;S SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 9'—�7— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C�- r L/ 7 Lil AT ION SEWAGE PERMIT NO. # V',IL L A G E # INSTA LLER'S NAME & ADDRESS 72� 8 UILDE R OR OWNER Lz DATE PERMIT ISS E D DATE COMPLIANCE ISSUED 1 �_' Z �� G C � I � �� I� ?�' �, �� �. �' z. N �. =� � �` -� ,� No.........�.... Fps... a............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF I-1 H EAL Application is hereby made for a Permit to Construct (16--Or Repair ( ) an Individual Sewage Disposal System At: . ..........SAJ :- 7..LZ9­,4 .---....... 1 ......... , . . ✓�Location- ddress W or Lott No.----------------------- .mo t ---------••------- n 7 J, Address ............. G�fs�7 }. ...............•-----... -----.................................. Insta er A dress Type Building Size Lot... ____ ....Sq. feet Dwelling—No. of Bedrooms.......... ---------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building°1�_ _ No. of persons......... --------------- Showers ( ) — Cafeteria ( ) Other fixtures --- ...................................................... Design Flow............. .. __.._______gallons per person eeda,� Total daff y flo f_______.j ._..____.__._.._.gallons. 1,e._._ _� ll W Septic Tank—Liquid capacity_/ gallons Len gth__ Width.. . _ ._/ iameter________________ Depth................ x Disposal Trench—No. .................... Width........ .._._.. Total Length-------- _...._ / Total leaching area....................sq. ft. Seepage Pit No...___.__./......... Diameter___..___..�_r. Depth below inlet__ __. Total leaching area__ sq. ft. Z Other Distribution box (l) Dosing tank ( ) % // aPercolation Test Results Performed by .....l,9rZ- ........ Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground wat 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. -/ W -----•------•----•----- - ---------------•-• -------- -------- -------------- --------------------------- •-•-------••-•-- O Description of Soil.......... Gf' ' 6 e.��......-- - - ..............................................................................x U •----------------------------------•---------------••---------------------------------- ---------•----------------------------------------------------------------------------------------------- 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 iITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ADed by the board o alth. ,� Sin - --------•----•-•--------•------- � p Q Date Application Approved By.....--. -•--- -------------------•--•------------......----- 0`-_- 1 `-- _.. Date Application Disapproved for the following reasons:- .................................---•------------------------------------------------------ ................................•••--......-••--•...--...--------•-•---•...••-•-------••...-------•----•------......------.......------------ ....................................................... Date PermitNo.......................................................... Issue ...d - --Date- �--•------•---------... No.._..... Y .. ' FEB... ..4 � ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH , ppliration for Disposal Works Tonutrurtion Vamit Application is hereby made for a Permit to Construct 4--or Repair ( ) an Individual Sewage Disposal System at* 20 .. Location-Address or Lot No > er y - ,o/ I' " Address ��a •--- .. (_�':dx4......:..... .• -`�-e`rc. — f.�-'�r-`.="Z.-t '1' ?.- ------..........................__,. a•••t1`•es -••--• -- .... Ir Installer UType of Building �1 Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms_____________ .....Expansion Attic Garbage Grinder aOther—Type of Building _e , of persons.........6.............. Showers ( ) — Cafeteria ( ) Otherfixtures-----------------•---••--•............................................................................_... . W Design Flow............. ..................gallons per person er d fay Total daily fly__.__._ �;s gallons. W Septic Tank—Liquid capacity./:= gallons Length._F- ___ Width__ __ _- Diameter---------------. Depth................ Disposal Trench—No ____________________ Width__._._._ Total Length........:''----- r. Total leaching area..__........_.....__s ft. x _. f g q• Seepage Pit No----------/-.__-__-. Diameter.__._.._. ._ Depth below inlet__ ____._._. Total leaching area. .:`x q. ft. Z Other Distribution box (�) Dosing tank ( ) ` `1 Percolation Test Results Performed by.'&�, , V----•`----- 7 ......... Date.. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground wat6r.................... , LL, Test Pit No. 2..._............minutes per inch Depth of Test Pit-------------------- Depth to ground wate� yam' _.•._ t: __ ._,: _' ................-•-•--•---•-••------------•••------------------••---••-- D Description of Soil... W Nature of Repairs o U P � r.:Alterldtions,.=Answer when applicable............................................................................................... ----------------------------••-------------------•-----•-------------------------------•--•--•-•--•---•...----••.•-•-•_-- 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 has been issued by the board of health. z' Signed ......f __ -------------------------------- Date Application Approved By................................ off------......-•----..........-•----------••-•--•--•------ Date Application Disapproved for the following reasons , .............. --.......---•.............................•....------------••------------------------------••-----........---------------•-------•----•-------------------------------...------------•-•--•--•-•...•-•-•- Date .. Issued._..•'..�/' 7 Permit No. ------------ ----------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH-. f t' t�......OF... ... '' ! �:. '� ... f�rr#ifixtt#r laf �nnt�gi�anrr THI ,IS TO CERTIF hat the I d'vldual Sewage Disposal System constructed (' or Repaired ( ) by----- � --='.................. / w? tt ...........,_•-- --------------------- --------------------------......------------ G t Installer 4 ` r - c` - -•-----•-------•---•-------------•- has been installed in accordance with the provisions o T F of The State SanitaryCode as descr'b d in the application for Disposal Works Construction Permit No. .___ ._�.t•�+r` ........__. dated ' .�*-- `"._ ._____...- THE ISSUANCE `OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W, ILL FUNCTION SATISFACTORY. �� �j C DATE......... -:.__� Inspector_, THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH j �tJ No............. FEE'' ....✓.............. !: i rya �t�,, nrk nay r imrn� rrntit Perm>ssion is hereby granted - ,.• ✓�, `�'' - ---- ,'1 to Construct ( ) or Re air ( ) �n Individual Sewage Disposal System at No.... �.`=VY ":f" t I Street as shown on the application for Disposal Works Construction Per ...... Dated.._ _�_ "'. f C ........ ............. -------------------------••- jC DATE....�----�-----•-•----•-----------------------•--•-•-------- ar o ea h FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ' M. 1 • t Poo dGClir' � F/N+S H G�Q.a D�•?�.• � r �t n�tSN v'•!PA G F >~►Nit' G4TA�Lx - { .0 'ek Ti4 NK _ Top oi�aerts. —` ti� ` I/,���11,�•II' r��c:'�.tfir`�r,+;��<�.%�1neq/-�r;�t✓/.�iti�,%/,�r'���� „ Ace 41 1600 SAL• 1 43.60 - "el N oc;becev CONGIA SE P7"f C Ti4^✓ AI�077" Ply- NG7 7 .s 4 No ! � E a da'7 �' ° i Y •{= ' ! ]� T P2DPoSre o look I N DruFL.L.I,L/F rd q dot F/n/AL ( I _ 4 q*' 6 stertc TA".iK.lip I - i t /8" 5u35o/� 4u r L ...... _ D.4 r� 2C� 1Gt r9 �7 F'Ete- eA rE. L 2/'M�x: /J�(!L N .>^�,o� /' — +?• . �..' r9?",d!' . M!`�_`J_.�/T Z /_ 14!c'. ►4 GF E^,5/ r2. /" 4c.:W T,au<7" MORI,.,At r.:rROAAt Vle f: Q�ittaRlths�r+ i •. t • ASSESSORS MAP : �Ap TEST HOLE LOGS NOTES: Z4, PARCEL : �`� 1) THE INSTALLATION MUST BE N SUBSTANTIAL COMPLIANCE WITH I" SO I L EVALUATOR :t.me'qE,'� R S ,CSr HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF oU FLOOD ZONE : BOARD OF HEALTH REGULATIONS. WITNESS : ����', :�� REFERENCE : Ib DATE : Nr; U3 __ 2) THE INSTALLER SHALL, VERIFY THE LOCATION OF UTILITIES, L YM/N PERCOLAT ION RATE 2 /nc SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO a CLASS LT19 INSTALLATION. 01. TH- I TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION � YONLY, AND SfiNYD I�`�1Z3h DETERMINATION.TLL NOT BE USED FOR PROPERTY LINE q / -LI.3 l s 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS LJ //Q SPECIFIED OTHERWISE) LOCATION MA P��� �) (J �a��(�S/ l v I 1 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A 38,i GARBAGE DISPOSAL. 9E.DiV R 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) 2��6 MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON.Z$ A BASE OF 6"OF CRUSHED STONE. r r 7.) EXISTI NL� &C" P(7- 70 86 I)V M Ptl) rwUsHt'-3 f38'r i -- ,. — -- — WA- q0 _- - m w/A//� or= oPas D SIC tf�tiY. 2` — __we�/a,�rfs _'or'>`rIA) SEPTIC SYSTEM DESIGN /°>/�0 Il�9K1RNL S_ �OAA I� L��/ 0(Z ��QrvsT+��ce FLOW ES I MATE 1 BEDPOOMS AT IIO GAL/DAY/BEDROOM - 33() GAL/DAY S� ►4Cb I �t� SEPTIC '�'ANK r ' 30� �� --;� ,, U GAU DAY x 2 DAYS GAL gg y -----� USE I C, GALLON SEPT I C TANK—�_' CIS77A; - <=� (�r;� K///scc,6,tL S T. IF SO i L A6'0'ORPT i ON SYSTEM i .r."fl�tl �ll�Mtf2� S I ° �/tVCf� t I v.J 2."L; S'Joj•c 0/Vt_r;0,5 2.S ` SIy/vr vtiJ SiUt_S .j� /�- iltv�t �J k k �/1 /:, SI E AR EA:C(`�O�Z-t�ir>�zZez- x a /y f l y0 a�, BUTOM AREA. X lQ X O, 7Z = 222 a I 3 �►� SEPTIC SYSTEM SECTION u S� i I 731�t= 7a F ° f�wcu-r Nc� � P 1, , a i __..._. __. _. �t, qq.6 M41 VEA/r T S d ( I o st :krr�al_�l,8 2 -3/8'jYL�b( I,cK h _ P7 W �E ul D 8�0 93 l� G Q ll 4� RE lk r ( COO GAL ` T- SEPTIC TANK _ J _ ��-r�r-�� oc/l �r NVe'•�s� IT I 1 C� (5xISTr&I 3/ - r � 4--�2 jar>v L l c. _ J I 5 V3 of 35 3L — — — _ \�V\OF MA SITE AND SEWAGE PLAN AMC C I C C � ; �;� o. 1�o � SS Iv LOCATION : 7 JUUT/-fpUk�T �F,r ?- �AA A./ls kH W OF Qs S' A0TAR\N' .--7 x PREPARED FOR : f�47 STEVEN Vlf/ $G} UMBA�' �� ti _ FSS0t'PQ,f -- DARREN M. MEYER, R.S. SCALE . No SUR DATE : �U i�U�, i��1 2 43 VINE STREET 1 DUXBURY, MA 02332 SS06 - DATE HEALTH AGENT (781) 585-0293