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HomeMy WebLinkAbout0011 HAMSTEAD LANE - Health 1l Hamstead Lane BARNSTABLE P 349 096 a w N I'M s If I; o � � I a TOWN QF BA.RNSTABLE LOCATION ICQU SEWAGE # LAG �U C+ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER _ PERMITDATE: COMPLIANCE DATE: S Separation Distance Between ihe: 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 ". 04 no A4 )bC rLU- /c�/ TOWN OF BARNSTABLE r o N l� SEWAGE # vS1 � �,4cc),/� ASSESSOR'S MAP& LOT�T INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) • j (size) NO.OF BEDROOMS BUILDER OR OWNER �� PERMIrDATE: COMPLIANCE DATE: c�— 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 - 74 1�3 LO Commonwealth of Massachusetts ZT. . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required for Cummaquid MA 02637 04/05/10 every 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. Important: A. General Information When filling out I forms on the computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return .key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address East Dennis MA 02641 City1rown State Zip Code 508-385-7608 S13742 Telephone Number License Number Cw3 I fl B. Certification Ln I certify that I have personally inspected the sewage disposal system at this address and that the "c,, information reported below is true, accurate and complete as of the time of the inspection.The inspection a C;,. was performed based on my training and experience in the proper function and maintenance of on site - n_ 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 04/06/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system-owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l� - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G1M , 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is q required for Cumma uid MA 02637 04/05/10 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will ..pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is Cumma uid MA 02637 04/05/10 required for q every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is q required for Cumma uid MA 02637 04/05/10 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters El due to an overioaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than V2 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. V Commonwealth of Massachusetts rs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is q required for Cumma uid MA 02637 04/05/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool'or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered ayes"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 , i 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required terCummaquid MA 02637 04/05/10 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping'information was provided by the owner, occupant, or Board of Health ❑ ® ,Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the,site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is q required for Cumma uid MA 02637 04/05/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 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 past 2 years usage(gpd)): 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: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required for Cummaq uid MA 02637 04/05/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 s ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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: 07/12/02 per BOH Yes No Were sewage odors detected when arriving at the site? ❑ ® I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required for Cummaquid MA 02637 04/05/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 7.3 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.): Septic Tank(locate on site plan): Depth below grade: 6.5 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 211 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" F 211 Scum thickness 11 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is Cumma uid MA 02637 04/05/10 required for q every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap {locate on site plan): Depth below grade: _ feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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) Qocate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required for Cummaq uid MA 02637 04/05/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cunt.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments M 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is q required fa Cumma uid MA 02637 04/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has three five hundred gallon drywells in a34'x13'stone field.There was no sign of ponding or failure in the stones. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required for Cummaq uid MA 02637 04/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required for Cummaquid MA 02637 04/05/10 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cons) 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. r ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Hamstead Lane Property Address Scott Ward Owner Owner's Name information is required for Cummaquid MA 02637 -04/05/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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. TOWN OF BARNSTABLE LOCATION �� f7 ����� � � L� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT--�7�'� INSTALLER'S NAME&PHONE NO. �¢� (24,VC0,. SEPTIC TANK CAPACITY 6; G3 /may LEACHING FACILITY: (type) ' (size) ix /3�XZj NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 6hellu 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 Le L 0 �� f,�3, L� a*No. Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for 13igpooal bps�tem Con.5truction Permit Application for a Permit to Construct( )Repair(✓fJpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. m5(,,414 0 1A kLAF— Owner's Name,Address and Tel.No. c3y q IAKA (5r;nne Assessor's Map/Parcel Installer's Name,AddreA 0 Bl.(MNCO Designer's Name,Add s and Tel.No. 350 Main Street rMe��r W. Yarmoutn, MA 02673 7 F1. SAS• Oa Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow VY7 gallons per day. Calculated daily flow 41410 gallons. Plan Date (c'oZ Number of sheets / Revision Date W A Title sife^ Se"t Size of Septic Tank /SUo Type of S.A.S. n Description of Soil PC f- iYACl Nature of Repairs or Alterations(Answer when applicable) r /7:/,4A,/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this o d o0fAlth. Signed t Date 2 . Application Approved by Date 6 4 " Application Disapproved for the fo owing reasons Permit No. 260—ZS7 Date Issued 2 4 �Y am*.awr No. s�, +}5. F Fee N THE COMMONWEALTH OF MASSACHUSETTS - Entered in computer: Yes k;PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Ipplication for Migpont*p6tem Conotruction Permit Application fora Permit to Construct( )Repair(,.-)'jpgrade( )Abandon( ) ❑Complete System_ ❑Individual Components Location Address or Lot No. / 9,4 m j'(,r a /- Owner's Name,Address and Tel.No. f Assessor's Map/Parcel L J. , f Installer's Name,Address, l&1 SoCANCO Designer's Name,Add gs and Tel.No. 350-Main Street 1'1►t yt W. Yarmout,,, tMA 02673 sFl S�S Oa 3 Type of Buildingw ti. ' Dwelling No.of Bedrooms Lot=Size f + + sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons' Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons.% Plan Date S'/(11•0� Number of sheets Revision Date Title S'i�e - c,r Size of Septic Tank ^^ Type of S.A.S. Description of Soil Vet"f- ?IAA.l 4 Nature of Repairs or Alterations(Answer when applicable) Pe.r ��a�✓ (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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this o d o/ Health. Signed 1 l Date Application Approved by I'✓ Date 6// G aApplication Disapproved for the foll��owing reasons o Permit No. 00?-aS7 �"r Date Issued -: ------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( _ i'`6pgraded( ) Abandoned( . )by _ i� �.4 aU L 0 at 1 1 f.(n,a,ti 15+,.u-9 4ttio� Cu AAwt;o,.;10 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.:)nn?- 2S-7 dated t6 / Installer ` Designer The issuance of pe it shall not be construed as a guarantee that the syst- will,fu}j ction as de i ed. Date "'7 1 k Inspector A .4✓ (" --------------------------------------- No. 0;?— 7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ligozal 6potem Conotruction Permit Permission is hereby granted to Cons�ct( )Repair(/.YUpgrade( )Abandon,( ` ) / System located at �7 � "ice Ile g�2 et P_ ��,.�,► G Co I'CYf 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:Constru tion ust be completed within three years of the date of thi permit. Date: ' r � Approved byIL �D �� "" " r � l COMMONWEALTH"OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: I I HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Address of Owner: 11 HAMSTEAD LANE YARMOUTH PORT MA.02676 Date of Inspection: 7/13/00 Name of Inspector: JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119.TEATICKET,MA.02636 PIP `"°•. Telephone Number: 608-664-6813 FAX 608-664-7270 / A* aq CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information/Irepo'ed beliiN's to;-accurate y and complete as of the time of inspection.The inspection was performed based on my training and experienceirirthe prope�functid`and ., maintenance of on-site sewage disposal systems.The system: 144 'e No% X Passes ConditionallyPasses m �O _ Needs Further Evalu By the Local Approving Authority h �O Fails Inspector's Signature: Date:7/14/00 The System Inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If th system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INPECT�ION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. I r �) revised 9/2/98 Page 1 of 11' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Date of Inspection: 7/13/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not. - n1a The septic tank is metal unless the owner o I r operator has provided the system inspector with a copy of a Certificate fcate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed v; Ipl 4.y . 4 ' revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WIT TEN Date of Inspection: 7/13/00 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic`tank and soil absorption system and the SAS is within 50 feet of a private water supply well, e; , 11: The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nAt(approximation not valid). 3) OTHER n/a t , ASS revised 9/2/98 Page 3 of 11 • t,.� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Date of Inspection: 7/13/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. - X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, _ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - X the system is within 400 feet of,,a surface drinking water supply X the system is within 200 feet of a'tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner: MRS.WITTEN Date of Inspection: 7/13/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. n•5 I revised 9/2198 Page 5 of 11 ;SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Date of Inspection: 7/13100 FLOW CONDITIONS RESIDENTIAL Design flow: 110 g.p.d./bedroom d Number of bedrooms(design): 4 Number of bedrooms(actual): Total DESIGN flow: 440 gpd Number of current residents:1 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a :sa Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a +p ; Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 14 YEARS OLD. Sewage odors detected when arriving at the site:Ores of go) NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Date of Inspection: 7/13/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 72" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 66" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 5'7"W 4'10 Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a 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 Comments: (recommendation for pumping,condition of inlet and outlet.tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a ink revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Date of Inspection: 7/13/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DID NOT EXPOSE DISTRIBUTION BOX IS 7'DEEP PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a { revised 9/2/98 Page 8 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Date of Inspection: 7/13/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments:' (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.THE LEACH PIT HAD 1'OF LEACHING LEFT AT THE TIME OF INSPECTION. CESSPOOLS: _ (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: n/a inflow(cesspool must be pumped as part of inspection)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 ,;a x revised 9/2/98 Page 9 of 11 t.if: • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN' Date of Inspection: 7/13/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 0? h� revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 HAMSTEAD LANE CUMMAQUID, MA 02637 Name of Owner MRS.WITTEN Date of Inspection: 7/13/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2198 - Page 11 of 11 , ,,,ASSESSOR'S MAP No. j�_PARCEL L 0 -C E 10 N -r- S E�WAGE PERMIT +N O.,. ( — V ti:t L A G S LA_vLe- INSTALL R'S kAM S ADDRESS B U I L D E R OR OWNER x� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED cZ7� � ya 3 y 44 j4� q- 94 No....... �xFim THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...0 F.... �s-�a-ble, ...... ................................................ 'Appliratinn for 11ispusttl arks Tonstrudiun Frrmft Application is hereby made for a Permit to Construct ), or Repair ( ) an Individual Sewage Disposal System at: i hs....o.. E 1-�aw►s�-�.�d l- - -Lod 5_ _P1:.t31 ._ 36 ► .P�. 3 ........ .. ........ ......---.......------r—•1' -- •- -- ..�. ..... Location-Address �..V V1ltwlou�V 1 q or Lot No. W ..........S ...._.........Ownet............. .......`........... ..............................•............. .-........................ ........... Address a ............. •.....................••-•-•--••-••---•........._ .......--••.. ...................................................................... Installer Address Type of Building Size Lot..4 9!_x! 6!..S . feet DwellingNo. of Bedrooms ...............................Ex Expansion Attic— p ( ) Garbage Grinder ( ) aOther—Type of Building .........:.................. No.. of persons............................ Showers ( ) - Cafeteria ( ) aOther fixtures .................•-----•------•--............--•--........................................----------......--•----•-•--............................--•- W Design Flow...............5........................gallons per person pl.Ir flay. Total da`i�y �iow.........-.- ....-..- . WSeptic Tank—Liquid capacity! ?!..gallons Length 8.Z.... Width;....3 L Diameter................ Depth.......�� Disposal Trench—No..................... Width... ........ Total Length:......Y.... Total leaching area.... ...._.........sq. ft. x , 3 Seepage Pit No.._.o!� ..... Diameter...O.Q. ..:Depth below inlet. .. . ..:. Total leaching area- 6 3Ssq-ft G'D Z Other Distribution box (x) Dosing tank ( , ) Percolation Test Results Performed b opt�bovti� �6 a y.......:.. ........... ...............r.. ..�y................. Date....................................... 6-1 Test Pit No. 1....a.......minutes per inch Depth of Test Pit....1..5�.1i. Depth to ground water..no��'..... f=, Test Pit No. 2................m>nutes per inch Depth of Test Pit..... 4 l.... Depth to ground water..:..................... , v1 ' Suto_......' o1 `�• ... oO f G . ') � ► _ S a �* 14`�...............oe , . ... ._ _ - � " > 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'LZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certi• to Com 1'ance has is ed b th/��/board f 1� lth. p Signed. `'S?�Q :.!:L .....(?e �� :^.............•-.•-. — .. . Dae t ApplicationApproved By......-•----•------•....•---•.............J ...... ..... ... •--• $ ........... Date Application Disapproved for the following reasons:.......................................................................................... ...........--- .......................................................•-•-................-----...........----....................---.................................................---•-------••---................. Date PermitNo........................................................ Issued............... ••-•.............................. Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I A m / �C(LJ LI DATA 4, Ficz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7TO.... ... . ....................OF.......... . ......................................................................... Application is hereby made for a Permit to Construct ('ll) or Repair an Individual Sewage Disposal System at: .............. ......... ................................................................... ... ............... Location-Address (—'J VV%'I---yQ I C-A or Lot No. ...........................................Owner ........................................ ............................................................................................. Owner Address ............... .................................................... .................................................................... ......... Installer i ,SAd�dress�f,14G't -_ Type of Building �, (_�3 S ize,Lot............................. q. feet Dwelling—No. of Bedrooms...... .................................ExpaLion Attic �Garbage Grinder Other=Type of Building :........ ............ No.. of persons.A................. ....!Showers Weteria Other fixtures ....................................................... I _0....................................................................................... Design Flow...........51S.........................gallons 1per person per day.. Total daily flow..........................................._gallons. gallons Length �.... Width:.41`-... Diaimeter.A.............. Depth.!T.!�A'.�' Septic Tank—Liquid capacity�,:�_ Disposal Trench—No...................... Width,..................... Total L�,enkth..IjO..:..' Total leaching a*rea....................sq. ft. Seepage Pit No....2n�•_..... Diametenl�..4='.i,.M, Depth below Total leaching area. 55sq.-ft.Gjc z Other Distribution box 0< Dosing tank Percolation Test Results Performed V- G-N ......................... .:. .... Date:. ?..................................... Test Pit No. I.......i........minutesperinch Depth of,Test,Pit.l:�...... Depth to ground Test Pit No. 2................minutes per inch lb�p_'dh 'of Test Pit..... Depth to�grourld,(water.... ...... 0 .............* !F .......... ...... ...... ........ ....... .......... Description of Soil.- _�A _- ( -D 7­� ZZ ........... ............ ---------- ........ ............... ------------ ........... ...... .................. ----------- 4 V, .................... ............................ I— A ---------------------------*---------------* .... ...:_4...V. .4 , ,.........T........................................ ..................... U Nature of Repairs or Alterations—Answer when applicable.... ..................................................... ............................................................................................................. ............................................�.,/........ ... .....t...........• . ......... .... V Agreement: The undersigned agrees to install the aforedescribed Indiyi�&al Se'wage,Disp.�l 8ystem-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 Ce7l �A�pliance has beeff-i-Mued by the board of health.� L Signed....... ..vA ....... ..................... ............................... D t Application Appibved By......................................... .......I .. Da Application Disapproved for the following reasons ......................................................................................................... ....................................................................................................................................................................................................... Date PermitNo................... O•f •. .............. Issued..--_..... ........--••-••--•-- ......... Dam THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH .........................................OF.......... ........................................................................... (Irruftrate of Tomphattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired bAk......................................................................A 1 ....... s4on .X) .................................................................... Installer at.. 1).........1(A.rbif6 �A .....(41 0 . ..................... ....................!��....�:­V . .ViA. .......................t............................... has been installed in accordance with the provisions of T1' 5 of The State Sanitary Cod 54e,,jr.b in the i ary 0 &:* application for Disposal Works Construction Permit No.... ................. dated........... 4t.......... ........... ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................. ............................................. inspector.............I.I.LLA ...................... ......................... THE COMMONWEALTHIOF MASSACHUSETTS BOARD OF HEALTH .......................................... OF...... ........ No......................... ..)__ 19topsal orks Tonstrurtion Pffmit Permission is here ranted ........*...........4*1......................................... ----i--4:........................... to Construct (/Xror re Air ividual P%K��490 Syew. at No Street Qx-s7z) as shown on the application for Disposal Works Construction Permit No..... ............... Dated........ ........ ......... ................................. ....... ................... DATE. Board 11,!.1t ......... ... . ........................................... -.c _ SECTION ' SEWAGE SEPTIC TANK- q( _«D"BOX- 4 ' -LEACH PIT - TOP OF FON 1 ` �ilGll K.✓..(MSL)!.. "2"OF t/aTO Ve" �83 WASHEO STONE 7� _ R ,�' i��-�aV�o►�f X 15D l(v GaY1�12 <g l O � 461 op q SUt3 OUT' IN4. • �' i:� p IN SEPTIC ` TANK :E ELEV. ELEV. LE EI EVr ELEV. b n "� ELEV. _ ELEV._ 7 IO i%' lilt _ � � � - ,./'" -�� ,��,..* ram•, t OF�i"=3Yt" •WASHED STONE M OF 1 N E� TEST HOSE LOG ��35� TEST 6Y r T 8 _WITNESS .• - F , ,�1 � , / �--�` `. pJ ; ��� . .T �O•Z �' 6 ✓ TEST DATE BEDROOM HOUSE T. s 1 T.H. r 4 NO L3M DISPOSER DISPOSER t'ERC RATE. MIN/IN.. t- 75,3 �2.3 FLOW RATE• jo. -(GAL/DAY ®.�� ~•.J} S t L-T f SEPTIC TANK 3�jo G• G� REO'DSEt'TIC'TANKStZE o E 1 - �] 1 / / - i c� ,t�:.S LEACH FACILITY. •: � . . '' �►,' � . �_ / . _ / G✓�9Q S. SIDE WALL T[� °.S 2Zs ,.IJ. u 1 --GID. -f - 1%�. 2,ZZ -sl 1A fob 3 BOTTOM' ;p•qZ! = G/D.. p TOTAL 26?, OSF �. 5 �. t': A� USE: C?d,1 . LEACHING •�i T •�IAtP �' � �j -. �� . WATER ENCOUNTERED Z.(/0 i F- 1 NOTES.-.' (UNLESS OTHERWISE NOTED) flF � rCpE,IT �jC�( 1.DATUM(MSL)=TAKEN FROM Yar1t)I S QUADRANGLE MAP 2:MUNICIPAL WATER 1 C- 6VA1LABLE 3.PIPE PITCH:'A"PER FOOT ARtdl N• ` 't' P IZ S • 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO• �. •44 Q" - Q3,lA� / S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. C!Y}I 7+s ��_ �t�63d� ��, xr5 �f_c IGi( I ! � - -' L�T 6.PIPE JOINTS SHALL BE MADE WATERTIGHT hdt). 3CT$2 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM•OF MASS. G c� STATE,ENVIRONMENTAL.CODE TITLE 3 Ir �C ���� ` �p�&! 4`I @�' ✓�V.-�� ej �_. SITE G ;AN_ 8. T%Adm5 IML- J Fot.Yt� S; k�o�cJ< a-+��c a..sp 'S+� %-C), �1CtYAL ,� -- LOCO$/J , REG.PROFESSIONAL ENGINEER ' REF: • P� dowfl ea a eIIjI�CQIf«g _ PREPARED FOR: p. iJ CIVIL ENGINEERS llihid � - , 23 � LAND SURVEYORS —————— BOARD OF HEALTH M •�� REG:LAND SURVEYOR- CONTOURS (EXISTING)............. SCALP (PROPOSED)-O-O-O-O- APPROVED DATE ��7^'� MA DATE. NOTES: ASSESSORS MAP : TEST TEST HOLE LOGS �a PARCEL : a�o ,-� 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH ti $01 L EVALU TOR : ► J(�t � ME�(E�. �-5 THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF �UMnnP(,Zv�9 'BAP, 5TIk&E BOARD OF HEALTH REGULATIONS. FLOOD ZONE : WITNESS: G I k-Q � REFERENCE:131L C DATE: A 3 'Z� 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLAT I N RATE: SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO SO tL. INSTALLATION. r TH- I TH-2 t 57,IN 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION 1t Q D ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE t.-L.. 5�.33 I �L-L- DETERMINATION. A SA'JyLuRr�t ��p 3 ShN 3 4 q 4) ALL PIPING TO BE 4- SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS � ► 54.75 .,a «� �Z SPECIFIED OTHERWISE) II�O leg,77 gW N I Oy fir/ g 5AWC joVp S�� LOCATION MAPr 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A t� 'fS� wM i " GARBAGE DISPOSAL: l -M1iVM 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) x7 j, �, G MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON C 15 7� 53,g f! 'pYrZ�l f A BASE OF 6"OF CRUSHED STONE. Y 6fC05 % t-`K.H PIT TO E6 PUM, n� .us► ??_. PUZO? 1+7 L47,b62J6 I No l9-ouNDWRT€& 013S. rvo C�¢ov,�aw,�7�L, G735. �, o K40VV+y P?-JVA7C W��..r S ULAJ 'OFF'RU � (�4[✓►fi • 9, a wet w tN IW r .� SEPT i -C SYSTEM DES I G N ia) //O VA-0&VC0 7y 1n V G!L TdvNN Dr-?.? —s "Iz V' ` FLOW ESTIMATE ►01���kg SVI , iS F-mpo -- .,� g� --' --, ¢ �I� GAL/DAY/BEDROOM - � GALIDAY .�a.�?,��'..Q+� �.��Nt�,� �w���- � BEDROOMS AT :�. \ ! SEPTIC TANK 440 GAL/DAY x 2 DAYS - d GAL /60 s. USE � GALLON SEPTIC TANK-EUSPA-A ' Z0044 w�/SJuv ce�.� �y4 r _ `� , \ syi SOIL ABSORPTION SYSTEM DA�4t ova. tJJt/G Sj , 000� -./ \ t \ ' 6 Aj"v lei ,�t" 51 DE . ..,y , X ?s k r Lrc/kc " ' \\ SIDE AREA: I_�33.,5 -I' (13)7,]kZ-k �,7� � /37,(o1 ° b p'7 \ s$ BOTTOM AREA: 33•5 Y 13 K 0.7y / SEPTIC SYSTEM SECTION , 6 yPf3 ram` 7,33 _ Q„ (o!�2-'-60 n/ ©E * of n�$ti �ar/� ✓36.-,tx� I a-,57.7s' � 9 As `� z;=D. 2 leV-,i t 2`� '�j�UvgtC- W45f» Syp c- P S�.o3 4 �► r--� w a vr SSs � S A-IV , DS60X S"� �6�, /' lnlsiGc TO y Conn T4� 6�✓ Ct `� � I 1 ,�` sc� GAL 57,63 ✓+f + �1 �1 �11=f�1 ,�/, 7 l lr �Gft�14�Ls1 u SEPTIC TANK / % =1' o✓r3i. ' o>✓ T�s�oz.� • Ott.; �9,9c/ FA r SITE AND SEWAGE PLAN 140 FLOCATION : CT-1UZ, PREPARED FOR : W11-4,t M ��A)A)Et.L DARREN M. MEYER, R.S. SCALE: z 43 VINE STREET DATE: N1Z DUXBURY, MA 02332 W DATE HEALTH AGENT (781) 585-0293 W 2