HomeMy WebLinkAbout0066 BUCKSKIN PATH - Health i ..
66' BUCKSKIN PATH, CENTERVILLE
%lYCC'CCl�® �e—a
UPC 'i2534�o. 2153LOR tQ
HASTINGS. 4N
c
C0.. -10. £ LTH OF MASSACHLSETTS g
_ EXECL TArE OFFICE OF E.s-WRO\ME\TAL AF ' 2
DEPARTMENT OF ENviRoNMENTAL PRO, ON
'a e ONE RZ\TER STREE i'. BOSTOIX DLA 0210t 461"1 292-o5ot
O�,C CSC
Z ,�g9g T COIF
OF ecretary
�4
ARGEO PALL CELLLCCI ! �04sor DAB �B. STR'-'HS
Governor C.t:uruss:oner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:(( Buckskin Path ,, Name of Owner Van _T o h n s on
C ent e V e Address of Owner:
Date of Inspection:/ �
Name of inspector:(0 ease Print) m. E . Robinson Sr.
I am a DEP approved s e inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinson Septic Service
Mailing Address: PO BOX 10 9. Centerville , MA
Telephone Number:
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-sit�2,
a disposal systems. The system:
ses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails p
Inspector's Signature: W Date: /j2
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
rev:Lsea 9/2/95 Page Iof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION 1co►rtinued)
'rop"Address: 66 Buckskin Path, Centerville
awner: Van Johnson
Date of inspection:
INSPECTION SUMMARY: Check C, or D:
A. SYSTEM PASSES:
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.
C MMENTS:
i
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.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate 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.
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 Iwith approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times=a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
y.
y •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 Buckskin Path, Centerville
Owner: Van Johnson
Date of Inspection:/;-
C. HER EVALUATION IS REOUIRED 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
T e
public health, safety and the environment.
11 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 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.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH IAND 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.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) THER
revise 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icontinued)
PropertyAddress: 66 Buckskin Path, W,enterville
Owner: Van Johnson
Date of Inspection: /z_Z I °l
D. S STEJM FAILS:
You mu t 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 'o
_ T Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ I Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
icesspool.
_ I Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. RGE SYSTEM FAILS:
You ust 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
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)
T e owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
o ice of the Department for further information.
revised 9 2 /96 Page 4 or 1 I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
PropertyAddress66 Bu.6kskin Path, Centerville
owner: Ian Johnson
Date of Inspection: `/a1
Check if the following have been done: You must indicate either "Yes- or "No" as to each of the following:
Yes, No
✓ _ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
v _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
-_� _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
f15.302(3)(b))
_ The facility owner (and occupants,if different from owner) were provided with information on the proper maintanaaasof
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_ PART C
SYSTEM INFORMATION
rroperty Address:-66 -BaPkakin• Path, Centerville
Owner: Vari" Johnoson
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:CJ(fU g.p.d./bedroom. 7
Number of bedrooms Idesign): Number of bedrooms (actual):�3
Total DESIGN flowL/s®
Number of curfent.residents:.3r
Garbage grinder(yes or no):A, O
Laundry(separate system) (yes or no)A0 ; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): e) ��y /
Water meter readings, if available (last two year's usage (gpd): f`7�T 7D AA h
Sump Pump(yes or no):16-10 ('
Last date of occupancy: —g 9Y006
CO ERCIALIINDUSTRIAL: /
Type establishment:
Design ow: opd ( Based on 15.203)
Basis of esign flow
Grease tr p prese (yes or no)_
Industria Wastent:Holding Tank present: (yes or no)_
Non-sa tary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last d of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECOI&449urce of information:
System pumppe as part of inspection: (yes or no) O 0
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF YSTEM
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
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)-,!I, U
revised Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address66 Buckskin Path, Centerville
Owner: Van Johnson
Date of Inspection: _
BUIL ING SEWER-
(Local on site plan)
Depth elow grade:_
Materi I of construction:_cast iron_40 PVC_ other(explain)
Dist ce from private water supply well or suction line
Diam ter
Com ents: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:/
Material of construction:12eoncrete_metal_Fiberglass _Polyethylene_otherlexplain)
If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 6 -,-� (-
Sludge depth: "3—.S !'
Distance from top of sludge to bottom of outlet tee or baffle:l�s
Scum thickness:
Distance from top of seum to top of outlet tee or baffler
Distance from bottom of scum to bottom°outlet tee .baffler
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of li luid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) d !� �„ / 'Lc. ja `,p L
GREAS RAP:
(locate on ite plan)
Depth belo grade:_
Material of onstruction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Dimensions
Scum thick ess:
Distance fr m top of scum to top of outlet tee or baffle:
Distance f om bottom of scum to bottom of outlet tee or baffle:
Date of I t pumping:
Comment
(recomme dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence o leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
crop"Address: 66 Buckskin Path
Owner: Van Johnson
Date of Inspection: 7
T1G OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate n site plan)
Depth b low grade:_
Material of construction: _concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensi ns:
Capacit gallons
Design ow: gallons/day
Alarm esent
Alarm vel: Alarm in working order: Yes_ No_
Date f previous pumping:
Com ents:
(con lion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids ar over, evidence of leakage into or out of box, etc.) -
PUMP HAMBER:_
(locate on site plan)
Pumps n working order: (Yes or No)
Alarm in working order(Yes or No)
Com nts:
(note ondition of pump chamber, condition of pumps and appurtenances, etc.)
revise6 9/2/96 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 66 Buckskin Path, Centerville
Owner: Van Johnson
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_L
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Altemative system:
Name of Technology:
Comments:
(note condition soil, sign hydracilure, level of ponding, damp soil, condition pfyegetatpn, etc.)
G a d, w
PESSR 00
LS:_
(locate n site plan)
Number a d configuration:
Depth-top f liquid to inlet invert:
Depth of s lids layer:
)epth of s um layer:
Dimensions of cesspool:
Materials o construction:
Indication o groundwater:
in low (cesspool must be pumped as part of inspection)
Comment
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate site plan)
Material of construction: Dimensions:
Depth of solids:
Commen s:
(note cc dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revise 9 2 9c Page 9ofI1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icorrtinued)
'ropenyAddress: 66 Buckskin Path, Centerville .
'wrw: Van Johnson
Jate of Inspection: p�L—z_
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)
IJ'G
33
1
e
-7 '3
revised 9;2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
SYSTEM INFORMATION Icontinued)
top"Address: 66 Buckskin Path, Centerville
Owner: Van Johnson
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
oC.
Estimated Depth to Groundwater 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
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
13_�y�
revised 9/2/96 Page 11ofIll
-7o . o L, 9
VII/
No.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativit for Di-nVi 3al Workri Tomitrnrtiun itumit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
66 Buckskin Path Centerville
....---•-•-•-•-•--.....-----••----•---•--•--•--.....----•---•------------------------------------- -•-••---•-----•-------•----------•----•----•-•.._..----•-••--•-•--....-•--------•...-•--........•.
Location-Address or Lot No.
C.Van .
Owner Address
a W.E. Robinson Septic Sere P.O. Box 1089 Centerville
------------------------------•----- ------------•--•-------•------------------------
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ---------------------------- No. of persons---------------------------- Showers — Cafeteria
P4 Other fixtures ............................... . .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter.--------------- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a .......................................... .............................................................................................
..•------------------
0 Description of Soil...................................................................................... -----------------------------------------------------------------........--•-----
x
U
x ---------------------------------------------------------------------------------------------------------------------------------------------------------------
Nature of Repairs or Alterations Answer when a 1 ab1e...Upgrade to Title V C0�j �q
U P r PP q----------------T"............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee ss d by the b d of health.
Signed ...............
.......�.1....� ... .. .....:............................. ................... .. ....................... ...
Date
Application Approved By ............ �n...-.�f'..L-�
Date
Application Disapproved for the following reasons: ........................................ ......... . . . ... . ....................... ..........................
.................... ......................................................................................................................................................................... ...... ........................................
Date
Issued
Date
Permit No. ....... .. ....- ,��d- -------------------- ....................... -- .................. .
Fizs3 0...0.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diopoittl Workri Tom6trnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
66 Buckskin Path Centerville
...-•-----------------------•-•---•------............-------•--------......-•--..........--------- --•-------------------------------------------•-•-------......------------------••---•------------
Location-Address or Lot No.
C.Van Johnson
•-----.._......---•--•--•................•-------------------------------•--------- --...------------------------..........••----------------••--------.............----••---.....-•--
Owner Address
a W.E. Robinson Septic Sery P.O. Box 1089 Centerville
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling— No. of Bedrooms.............................. .. _Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( }
al Other fixtures ------------------------------- ......................
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter_------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No--------.--_------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
4
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water...._._.._...._.........
f14 Test Pit No. 2................minutes per inch' Depth of Test Pit-------------------- Depth to ground water........................
tx --------------------------------•-......------...........------•-------------------...........------.........................................................
0 Description of Soil.......................................................................................................................................................................
x
U ....-•--------------------------•-------------------...------------------------------------•--------------•--------------------------------••---•-----------------------------------•---•--------------.
w
-------- - - ---- -------------------------------------------------------------------------------------------- - -- ---- --------------------------------
U Nature of Repairs or Alterations—Answer when appli able.__Upgrade to Title V UOb c�ra r
f . f--------------( . .
tA"' _------...D....f x.._..y � f ..... ------Stew __-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be %ss ed by the bo,9rd of health.
Signed --------- /.1 -
L
................................................................. .................Date_...._..._......
Application Approved By ............. ............... ..-...� .........�,1
Application Disapproved for the following reasons:
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- .............................
Permit No. -------
..Lf... `7.. -- Issued
------
Dace
------------------- ------------_ --.------- ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(11'Er#ifi a e of Comylianrxc
TH IS 0 C.ERTIFY, Tha he I dividual Sewage Disposal System constructed ( ) or Repaired ( x )
4v. l�obinson Sep is Sery
by ---------------_.._...--- ----------------------------------------------- ---------------------------------------------------------------.---..----------------------------------------------------------------- ---------------
Installer
66 Buckskin Path Centerville - _...... -
at ..... ------------------------------------------------------- ---------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _. ..` ..---- ....... dated fn-_. _..../...-----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...--------.,1...�.... �.� r.�---- ------------- Inspector ;------ ��------- - -
------------------------------ -----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 30 00
No. /: �-7 FEE........................
�i�po�tt1 ork� C�nn�tr�r#irin �rrntit �
W E Robinson Septic---Sery _.._..._
Permission is hereby granted . . .. ...... ............... --•------- ---- --...
to Constr ct ( ) or Repair (.x�l an Individual Sewage Disposal System
hub Buckskin Patn Centerville
atNo............................................................... •--- -------------------.....--------------------------------------------------------------------------- ......................
Street
as shown on the application for Disposal Works Construction Permit No------------ �__ Dated------� ........
C� ..........................
..r f -------------------------------------------------------------•-
/ r 1..................................• 1 / Board of Health
FORM 3650a HOBBS R WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION z tct<�ktt- k SEWAGE # 6° ,
VILLAGE ASSESSOR'S MAP &LOT12A
INSTALLER'S NAME&PHONE NO., � &o"A J-t?l
SEPT C TANK CAPACITY
LEACHING FACILITY: (type) T/1' (size) eta
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: I&J69 COMPLIANCE DATE: �/31 A&
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) v Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching cijity) Feet
Furnished by ��� -�'�Al
M= e
V