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HomeMy WebLinkAbout0366 GREAT MARSH ROAD - Health 366 GREAT MARSH RD. ,CENTERVILLE A=190-100 UPC 12534 I i No.2-153_ HASTINGS,MN COMMONWEALTH OF MASSACH€JSETTS EX UTIV M E OFFICE OF ENvIRONEIVTAL AFFAIR S DRP_;kl MRNT OF ENVIRONMENTAL PROTECTION U 100 TITLE 5 c1� OFFICIAL INSPECTION FORM—NOT FOR VOLUI TARY ASSESSME TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �f /vtetr�G d(� 3.2 Owner's Name: 460!- u- J dt" beyrA e- Owner's Address: Date of Inspection.-LC-- Name of Inspector:(please print) 5 w,?Ar zn Company Name: � r ` z Mailing Address; 9 k­-It--e,- r el Fel [3oZ5.C Telepboue Number: 309-YCiS�=CF l�s t 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 ofthe inspection.Time 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 spproved sysiew iu pei-ia r-pursuani to on I5340 of Title 5(320 CMR I5.600). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fasts Inspector's Signature. Date.- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health cq. DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flflw,of I0,0G0E gpd or greater,the hwpecrtur and#toe system owner strap submit the report to the.appropriare regional office of the— DEP.The original should be sent to the system owner and copies seat to the buyer,if applicable,and the�;approvidg_?, ry authority. C___ - C Notes and Comments `o ****This report only describes cctudifions at the time of inspection and under the conditions of use � that time..This inspection.does nos£address how the system wilt ptrform hk the future under the same or MrentC) conditions of use. T41.4 T»cr.xrtin»Rnrm 4114MAt)n A Page 2 of 11 ICIA.E #SPELT N FORUM—NOT FOR VOLUNTARY ASSESSMENTS SUBSLWACE SEWAGE DISPE)SAI,SYSTEM.NSPECTIO2N FORM PART A CERTIFICATION (continued) Property Address: 34' 6 r"�� ���4 Owner: Date of Inspectsv0: Iirspec:tion Summary, C beck 4AC,D or E I AL &yS comPiete all of Section D . .b System Passes: not found any information whieit judjc-ate~;that any of the failure criteria described hi 310 C1Vf R 15.3J3 or in 31 Q CIVIR 15304 exist.Any failure criteria not evaluated are indicated below. comments, B. System Conditionally Passes: One or more syswm components as dese ritsed in the"Conditional Pass'}section need to be replaced or repaire&The system,upon completion of the replacement or repair,as approved by the Board of Healdt,will pass. Answer yes,no or not determined(YN,rN�M)in the for the following statements.Ff"not determined'please explain. The septic tank is metal and over,24t yeas old*or the septic tank(whew metal or riot)is structurally unsound,exhibits substantial infaltratum or wdilvation or tank failure is imminent.Symm win pass insprcd if th existing tank is replaced with a complying ScPdc tank as agisrvved by the Board of Hcalth. *A metal septic tams will pass iiispectiorn if It is stmc2uratly sound,not leaking and ii a Certificate of Compliance indicating that the tank is less tisan 20 years old is available. ND e-.Tlain: Observation of sewage backup or brew out or high static water level in the distributions box due to broken oz obstructed pipe(s)or-due to a brolkeft,sended or uneven i wa—AYati€rn boll System,wul paw bL%Xc*ion if(with approval of Board of Heal i,): broken pips)are replaced obstruction is awed distribution box is leveled orreplaced ND eVlain: The system requited pumping more than 4 timbes a year-Cdae to man or obstructed pipe(s).7-10 system will pass inspection if(4ritli approval of the Board of Health): €token pipe(s)are replaced obstruction is removed NTTD explain: • --a Pai=e 3 of 1 OFFICIAL INSPECT40N FORM-NOT FOR VOLUNTARY ASSESSIME34"TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTMCATION(continued) Property Address: -3(0(- (tee f) rs tel Owner Date of inspection: /0-l3 i3L' C.. Further Evaluation is Required by the Board of Health- Conditions exist which=Tuirc fw thcr evaluation by the Board of€health is order to determine if the system is failing to protect pz blic health,safety or the environment, 1. System will pass unless Board of Health determines in accordance with 310 CMR IS-M3(1)(b)that the system is not fundliiini g in a manner which will proud public heakb„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 rriarsh i. System will fail sinless the Board of Health(and Paib#e Water Supplier,if any)determines that the system is functioning in a manner fiat protects the pub is beaW safety and environment: _ The system has a septic tank and sou absorptim system(SAS)and the SAS is within 100 feet of a surface ester supply or tributaiy to a surffke wner supply. _ The system has a septic tank arri SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of mivaie water supply well. = The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feel-csr u e from s private water supply well".Method used to date ane ice ,. `*This system passes if the well water aniulysis,perfiarmed at a DEP certified laboratory,for coliform bacteria and volatile mgmic mmpounds it dts- -that the v.,ell is tree from poiltion fmm that facility and the presence ofammonia nitragea and aiemw ni&US an is oquad to oc hxs than 3 ppm,provided brat no other r"ailure criteria an triggered.A copy ofthe s€lysis mug€--anaened to*is k m. 3. father: r Page 4 of I I OFFICIAL INSEECTVO_FIRM-NOT FOR ijOLUN'TARY ASSESSMENTS SUBSI, ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address. L6 6_-2a Own", Date of Inspection: is—!a D. System Failure Criteria applble to all systems: You must indicate"yes"or"no"to each of the following for ate=moons: Yes No i/Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool tl Discharge or ponding of effluent to fne surface cif the ground or surface wafers due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert clue to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is Iess than fir blow invert or available volume is less than'A day flow .Required pumping more than 4 times in the last year 4E?T due to clogged or obstructed pipe(s).Nwnber Of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or priory is within 1€0 feet of a surface.rarer 5uDp1V or tributary to a surface water supply. c�Any portion of a cesspool or privy is within a Zone I of a public well. _ _/Any portion of a ceaspotai 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 SO 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 i-Negies ihat the went is free&wn pollugott From ih*i iaciRy and;lie preituct-of ammonia Aiieogera and nitrate nitrogen is equalts ter less than 5£rpm,provided that no other failure criteria are triggered.A copy o¢the analysis must be attached to this t'orm.j l t✓i E' f o)no ag stern d I have determined amt one or more ofthe above failure erizeda exist as described in 310 Cla R 15.303,therefore the system fails.The syvem owner should contact the Board of Health to deter=e what will be necessary to correct the imiiure. 1. Large Systems. To be considered a brge system the system must serve a fadUty V tln a design ftw of 18,O8 glad to 15,E tt�d• You must indicate either"yes"or—no—to each of the following {The following criteria apply to large systems in addition to the ciiirsia above,, ves no the system is within 400 feerof 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 WelLtsead 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 sigaificant threat,or answered „yes"in Section D above the large system.has failed.The owner or operator of any Fare system considered a significant threat under Section E or failed undcr Section D shall upgrade the system in accordance with 310 CVdR. 15.304.Th system owaer shviuld co ttactilie apgropriare regional office of the Department. Page 5 of 11 ()FFICIAL INSpECMN FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISpOSAL-SySTEM INSPECTION FORM PART B CHECKLIST Property Address: �Yvuer: Elate of lnspectivei: Cheek if the following have been done.You must im ucate"yes-or-no"as to each of the-following: `fes�No _ pumping information was provided by the owner,occupant,or Board of H�ith Were any of the system components pumped ottt in�e peons two weeks i/ Has the system ived normal flows In the previous two wt-ek paeod? V Nave large volumes of water been bmnduced to the system recently of as par of iuis inspection ✓ _ %ere as built plans of the system obtained and examinei r(HE they wee not avaaiable note as MA) _� Was the facility or dwelling inspected foi signs of sewage back up? i1 � Was the site imocewd for sib or creak out? 1/ Were all systern cornpcments,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of'Ie tank inspected for the condition ui[ite�oaflies or tees,material of construction,tensions,depth of liquid,depth of sludge aced depth of scum? — Was The f'acWEy owner(and ors if diet firm owner)provided with inforeastion on the proper maintenance of su'asua:ace sewage disposal systems? The size and loess n of the Soli Absorption System(SASS)on the site has been determined based on: Yes no Existing information.For mraple,a plan at the Board of Realth. __ Determined in the field(if any of the f fflure criteria rela i to Pat-t C s at issue approximation of distance is unLceptable)[310 CMR 15302(3)(b)) Page 6 of I I OFFIC AI.INSPECTION FORM-NOT FOR V€€ LU? ARY ASSESSMENTS S SUBSL-RFA.CE SF AGE DISPOSAL SyS`IFm INSPECTION FORM. PART C S a STEXI rTORMA T ION Property,address: ?f� Owner; Bate of Itespeceio FLOW CONDITION IS RESIDENTIAL Number of bedrooms(desiga): Nutrnber of bedmums(actual): DESIGN flow based ore 310 U R 15?43(S��c7:atrYple: 11C bid x#ofbed=v tom): Number of current residents:-_ Does residence have a garbage grinder(yes or no):Izo Is laundry on a separate sewage system(yes or noy J/p€if yes separate inspection required] Laundry system inspected(yam or no): ' Seasonal use:(yes or no): water meter readings,if ay gable Clast Z years usage(gpd)): Sump pump{yes orno):. Last dale of occupancy: /!I-13'C 5 COIb;r MERCLUffIl"-?DUSTRUL Type of establishment: Design Ffow fbasad oft 3ff3 C:MR 15.203): Basis of design flow(seats(persons/sq:`t e=): Grease trap present(yes or no):— industrial waste holding tank present,(yes or no):_ Not}-sanitary waste discharged to the Title 55 system(yes or nc)): Water meter readings,if available: Last date of occr.panry fuse: 0—i HER(describe): Purr-ping Records Source of information- <_ r" die / e VK 5:he� veGj Was system pumped as pant ofthe on(yes Gr ao):_ If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: 11Y19 OF SYSTEM —Septic tank,distribution box,soil absorption system Single cesspool —Overflow cesspool ____Privy Shared system(yes or no)(if yes,attach previous inspections records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from syswm owner) Tight ht tank _Attach a copy of the DEs approval _Other(describe): ft.pproxirnatc age of ail components.clue ftL rw lcd(if kmawn)and sot nc:e of information: M's Were sewage odors detected when aniving at the site(yes or no): ��o h Page 7 of 11 OFFICIAL L WSPECTION FOW&—NOT FOR VOLUNTARY AR SEES MIEN€S SUBSURFACE ISEWAGE DISPOSAL SYSTEM 1—NSPE CN FORM PART C YS M MFORNMATION(conti ued) property Addrm: A6 6a,-e f Aar ge nt�rt�.it Owner; Hate of erection: BU°h DI VG SEVV ,Iozaw on sYW pLa) . 41 M—a- _�L^f_'4�38LFLCLtOCt sT t7t3i1 40 PVC iother.(explain): pi"m ee f wr Pirate` at-T supply well or suction line: 4^omments(obi cond.`don of joints,dig, id,e Ce of laika - sEPTI`v TANK:_(legate on site plan) Lh;veh 4t� Nm4 terial of cone -fiber other(eOlairl) _ aF.ry ,3 1. ../'��..:.,, f u f T ' t Ca x.s,r'1.ed b a ti �xtc s:'u; o � mp!iawe(es or no?:�(attach a cap} ol certificate) Dimensions: I G •'�, io" !$6c C l Sludge depth: " Disa�c r�:a n a.Igc`'Z uu:u,.0 vi uutic6 We or baffle: Cw Scm Lhickness: tl;.•egw.•r.£mm try�+.nfnr-.,•z tt+,t!X1€lI'A,t:??t toE of 1?2�C: �ry.�r,-��r�, / Distance from bottc,-of&--ma.to quoin o-^�=� e or baZle. How were damenmons de mcd � tart� :' ,..'..��.: .,.. Ak';r5;?�'.'.r a: ^_. .Car +^fT?t _ inn cs-f> »I:�integrity,iSCI3I levels as re'ated to , Iz ¢ZkCE of leakage,etc,): GIVZASE'l-4''_(ixate on stte plan) Ecpth bw-20w grade-_ lateriai of canstr etacr:; ::> t l—�; 4s-ti Dimensions: Scum thicluiess:_ Distance front top of ;Cuju€o' "'-���f�:i��=iG"L. �Cii.v. Distance f om bottLrn o sLum;m u=o a 1 on last p7uw+iag. -- -+ c,..Y P� - - .....1__�__`�;;,T:�,.....� ":__...._.y..�.,,...w., ..,-,. 3d. evels Page 8 of I I OFFICIAL INSPECT ON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM[ PART C SYSTEM INFORMATION(continued) Property Addrem; 36fv 6-aa S�,r"�'rrfi nle Owner Bate ofInsgectiou: TIGHT or HO; DRiG TAN-&- (tack must be pumped at time of in.�on)(locate on site plan) Depth below grade: Material flf`construction: concrete metal fiberglass__Polyethylene other(explain�: Dimensions: Capacity: allons Design Plow: gallonsiday 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; tf present must be opened)(locate on site plan) Depth of liquid level abovc oimalct i�vbrr Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage intp or opt of bqx etc): geatsd kin PUINO CHAMBUL (locate on site plan) PuBtps in woddog order&cs or no). Alarms in working order{yes or no): Comments(note GOWiWn of pump chamber,condition of pumps and appurtenances,et,): Page 9 of I I OFFICIAI.INSEEC i DN FORM—NOT FOR VOLUNTARY ASSESSMENTS SURSURI ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTENI INFORMATION(continued) property Address: _-- Owner: Date of inspection: SOIL AWORPTION SYSTEM(SAS): (locate oa site plarx,excavation not required) If SAS not located explain why: Type leaching pits,number. leaching chambers,number leaching galleri;cs,number leaching trenches,cumber,length: leaching fields.number,dimensions: overflow cesspool,number. innovative/alternative system Typelname of technology: Comments(note condition Of soil,signs DfbydmuUc failure,level of ponding,damp sail,condition of vegetation, etc.): q rt - t frct+,, -cr -t `X35 CESSPOOLS: (cesspool must be pumped as part of inspectionXlecate on site plan) Plumber and configutstim 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 ofponding,Condition otyegetation,etc.): PRIVY:—(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic feature;level ofponding,condition of vegetation,etc), Page 14 of i i OFFICIAL INSPECT I N FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION{continued} Property Ad&ess: J%4 6- -d ilurs4 96 C���e-v:Ile Owners Date of Inspection: 1C-13 e)6 _ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or ben chnmrks.Locare all welts within 100 feet,Locate where public WaWr supply enters the building. _ i • 6 i i t r` �� i Page I I of I I OFFICIAL INSPE ON FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) proWty Addrem 36 Owner: Date of Inspection: SITE EXAM Slope surface water Check cellar Shallow wells Estimated depth to ground water 62'feet Plowe indicate(check)all methods used to determine the high ground water elevation: ✓(3btaine�d from system design glans on record-If checked,date of design plan reviewed: �/ bserved site(abutting propertylobseavation hole within 150 feet of SAS) Checked with local Board of Health-exxplam. r7"Checked with local excavators,installers-(attach documentation) =Accessed USGS database-explain: You must descn'b how you established the high uound water elevation: j� j w= N� AU a` G-e- f�'" fries Title 5 Inspection Farm&1512000 11 rCIIIII w4.1,r /Cam/ TOWN OF/BARNSTABLE a LOCATION SEWAGE # �—S�O VILLAGE Cell J!//'/�� ASSESSOR'S MAP & LOT ® leO INSTALLER'S NAME&PHONE NO. �r�Lc� % LB�s�` ^�P' SEPTIC TANK CAPACITY /SDD CMG 11 LEACHING FACILITY: (type) lY9a� L-0 (size) /a',K-3o'l-a NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 9 -/ems 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 4t 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 s 344 00 �o d�a1' No.jv_ 15_yl:�11Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Ii-4poof *pgtem Construction Permit Application for a Permit to Construct( )Repair(r )Upgrade( )Abandon( ) 0Complete System D Individual Components Location Address or Lot No. L� / r�j j� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: ��a Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ' Other Type of Building 116 16 e1✓G�No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ll,,2' gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 15`D7e Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7`d7`6t� � /-2!y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuedby t is oard f Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued f�` —— �� 3 v' .54 0 / / TOWN OF BARNSTABLE LOCATION �b SEWAGE # VILLAGE Ce11 ASSESSOR'S MAP & LOT fG' Ie INSTALLER'S NAME&PHONE NO. fp'orl"`rZe-- ' eg�,sl` SEPTIC TANK CAPACITY lion 6.G LEACHING FACILITY: (type) ltu (q) (size) /o',-30',Ka NO.OF BEDROOMS 3 BUILDER OR OWNER Cy1B�'/1 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility st Feet Private Water Supply Well and Leaching Facility (If any wells exist � on site or within 200 feet of leaching facility) 4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by No. `� Feed V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: c Yes PUBLIC HEALTH DIVISION - TOWNi OF BARNSTABLES MASSACHUSETTS ZIpplication for Migpozal *pgtem Con6truction Permit Application for a Permit to Construct( )Repair(►' )Upgrade( )Abandon( ) OJ Complete System Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. /47 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. BDt toGv�'`� Coszs�` 7 Type of Building: � Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ee Other Type of Building 1Ze316Z1)eWe-e No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow - gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 15257e Type of S.A.S. Description of Soil 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 Environental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y t is oard •f Heath. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ————- ------------- -- ——---—-—— ———�-— THE COMMONWEALTH OF MASSACHUSETTS 19 —lVd BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE =, that the On-site Sewage Disposal System Constructed( ) Repaired(Ve)Upgraded( ) Abandoned( )by/ S at b l� - !! CG 7�fL4 f� has been cons ted in/accor ance with the provisions of Title 5 and the for Disposal System Construction Permit No. �-. � dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. � �`Y�,l O'��-----------------= I ��w �—Fee IS-0— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS migozal *pztem onotrurtion Permit Permission is hereby granted to Construct( )Repair/( Up rade( )Abandon( ) i System located at _�?4tt ?�`/l�G!'S�7 ✓ 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 date of this,permit. Date: Approved by l i tor9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at ebb ��2Q� ���°� 4:5,0' 6��/--.-meets all of the following criteria: V here are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 1-40 feet of the proposed septic system There is.no increase in flow and/or change in use proposed ere are no variances requested or needed. If the proposed leaching facility will be located within =50 feet of any wetlands, the bottom of the proposed leaching facility will =be located less than fourteen (,I-) feet above the maximum adjusted groundwater table elevation. Please complete the following: 1G� A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) t/ B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.art t 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at meets all of the following criteria: . There are no wetlands located within too fee:of the proposed leaching facility . There are no private veils within !=0 feet of the proposed septic system .There is no increase in flow and/or change in use proposed • There are no variances requested or needed. if the proposed leaching faciiiry wiil he located vithin:50 fee:of anyweaands,the ronom of:he proposed leaching Caciiiry will IL4.t�e iocated less:han Caurteen i,:-1 fee:above:he maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) # B)Observed Groundwater Table Elevation(according to Health Divisiorrweil:nap) SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. 4F haltb haler:eat 000 36� �4 (LD �u V vx �. v � d rn v 0 i J II j'l a a w jr z 6 < n m U rt o L a -1 1po a 1 m c L a T Z., z - - 1 O N . b � w s 00 �. rt 1 1 ") v m CiN rn Z 0 c.� Z � f ikl 70 U no z .