HomeMy WebLinkAbout0170 GUILDFORD ROAD - Health 170 GUILFORD RD, CENTERVILLE
A=171-070
Owiford, NO. 1521/3 ORA
&k1YAJ,4WN OF BARNSTABLE
1
LOCATION 7� r4,0 •/ SEWAGE #
VILLAGE (,en Z?111l11K,- ASSESSOR'S MAP & LOT /2f__07-0
INSTALLER'S NAME&PHONE NO. I�pf
SEPTIC TANK CAPACITY 11660 G k
.n a
LEACHING FACILITY: (type) 1 g 1 1N�c A � (size) rot e
NO.OF BEDROOMS
BUILDER OR OWNER T ��
PERMITDATE: - Z®—P COMPLIANCE DATE: -7 0
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
A,3 _ 96
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33
9'3 3q'
3
Cominonwealth of Massachusetts
Executive Office of Enviroiunental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 .titlepti
' D.E.P. Titlee S V Septic Inspector
P.U. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor —
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 170 Guildford Rd.Centerville Map 171 Lot 070 Address of Owner: ell
Date of Inspection: 612/98 (If'different)
Name of Inspector: n(a Roper
1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name, Address and Telephone Number: '`,G 1L'9�96
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information repo blow 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-site sewage disposal systems. The system:
_ Passes This Inspection Is based on criteria defined In Title V
_ Condibmit
Passes code 310 CMR 16.303.My findings are of how the system Is
performing at the time of the inspection.My inspection does
_ Needer valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
X Fails septic system and any of Its components useful life.
Inspector's Signature: G/ Date: 61s1g8
The System Inspector shall s copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
_I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
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
CoMpllance(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 conforming septic tank
as approved by the Board of Health.
(revised 04127)97)
One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 170 Guildford Rd.Centerville Map 171 Lot070
Owner: Roper
Date of Inspection:612199
_ Sewocte backup or.hreakout or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
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 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 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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
x I have determined that the system violates one or more of the following failure criteria as defined 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 in 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
cesspool.
SAS is in hydraulic failure.
trsvlsed U77197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 170 Guildford Rd.Centerville Map 171 Lot070
Owner: Roper
Date of Inspection:612198
D]SYSTEM FAILS(continued)
Yes No
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):
Numbers of times pumped
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 1 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"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
_ 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 bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised OOD97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 170 Guildford Rd.Centerville Map 171 Lot070
Owner: Roper
Date of Inspection:612199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_x_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None.of the system components have been pumped for at least two weeks and the 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.
_c_ — 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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
X Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
unacceptable)]15.302(3)(b)]
(revised 04127)97) p
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 170 Guildford Rd.Centerville Map 171 Lot070
Owner: Roper
Date of Inspection:612199
FLOW CONDITIONS
RESIDENTIAL:Design flow: 33o g•pd./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 1
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
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: nra
Last date of occupancy: nra
OTHER:(Describe) We
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: n/a
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date Installed(if known)and source Information:
26 years
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04r27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 170 Guildford Rd.Centerville Map 171 Lot070
Owner: Roper
Date of Inspection:612198
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 15"
Material of construction:x concreate_metal_FRP_Polyethylene_other(explain)
If tank is metal, list age Na . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: t.e'6"H5.7"144'1l0"
Sludge depth:7"
Distance from top of sludge to bottom of outlet tee or baffle:20"
Scum thickness:4"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 14"
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.)
Septic tank and all components are structurally sound.Recommend pumping system every two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain}
Dimensions: rda
Scum thickness:nIa
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:nla
Date of last pumping;,,_
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.)
nfa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: K
Material of construction:_cast iron_40 PVC_other(explain}
Distance from private water supply well or suction line?ow
Diameter. nia_
Qmments: (conditions of joints,venting,evidence of leakage, etc.)
(revised OMD97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 170 Guildford Rd.Centerville Map 171 Lot070
Owner: Roper
Date of Inspection:612198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Ma
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: rda
Capacity: rda gallons
Design flow: rda gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Y.s
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
17
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 170 Guildford Rd.Centerville Map 171 Lot070
Owner: Roper
Date of Inspection:612199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits,number: octagonleachplt
leaching chambers,number:Na
leaching galleries, number: nta
leaching trenches, number,length: Na
leaching fields,number, dimensions:nla
overflow cesspool, number:nla
Alternate system: nra Name of Technology:_Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit la past the effective depth of leeching,system Is In hydruallc fallure,system was full atthe time of the Inspectlon.
CESSPOOLS:
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: Na
Depth of solids layer: Na
Depth of scum layer: Na
Dimensions of cesspool: Na
Materials of construction: nla
Indication of groundwater: nla
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: nla Dimensions: Na
Depth of solids: Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na
irevlsed 04117197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
170 Guildford Rd.Centerville Map 171 Lot 070
Roper
612198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
�3(3 3°I
Pape 9 of 10
(revised Odf27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
170 Guildford Rd.Centerville Map 171 Lot 070
Roper
612199
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised04127197) page 1t1 at 10
No. l t" Fee —<2)J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
\ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0pplication forth nt/o�aY �pgte Congtructtou �e/rrrttt
Application for a Permit to Construct( )Repair(`/)Upgrade( )Abandon( ) ElComplete System L✓JIndividual Components
Location Address or Lot No. /�� �/+ /���, r Owner's N me,A ress Tel o.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
,Oe/.71MPAI Za-V61'
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(�
Other Type of Building >� eLGNo. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 330 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank f®®® rg AX%97lJ'i'9 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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this B d ol Health. J
Signed Date
Application Approved by Date
Application Disapproved for the Ulowing asons
Permit No. VA Date Issued
TOWN OF BARNSTABLE
LOCATION 7P /�1�/l"6'/�J" SEWAGE #
VILLAGE Lien y��'T/�'I�� ASSESSOR'S MAP & LOT 121--e7�
INSTALLER'S NAME&PHONE NO. � � �
SEPTIC TANK CAPACITY 166-0 C�a.
LEACHING FACILITY: (type) (size) i��T X I Ix
NO. OF BEDROOMS J
BUILDER OR OWNER ��'—�0
PERMITDATE: '7—ZP- P 9- COMPLIANCE DATE: —7
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
A-3 -
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� + 33
9'3 —
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No. Fee
t V 4
,
i
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes }
0(pplication for Migozal *proem Con!6truction Permit
Application for a Permit to Construct( .)Repair({/)Upgrade(^ )Abandon( ) ❑Complete System e Individual Components
Location Address or Lot No. `�D Owner's Name,A ress d Tel o.
(7
Assessor's Map/Parcel GgN �rv� /�/ _
I Designer's Name,Address and Tel.No
"�' t3o�Go�i�oasT. ��
Installer's Name,Address,and Tel.No. _
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinr.(
Other Type of Building �ewee o.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /1,49 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
'af Size of Septic Tank /000 9Q �X/S?`!�9 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: 1
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 beeri issued b this Bo d of Health. l
Signed; Date
Application Approved by Date
Application Disapproved for the following% sons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS 1-7/iOV
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( pgraded
Abandoned( )by
at 1 ' e" e has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. • t dated
Installer Designer °
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
1
a
- - ---�}--------------=-------=------=----ry-- i
No. Y — t' 7l 07� Fee �U
. r
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi!6POaf *p5tem Con5tructiou Permit
Permission is hereby granted to Con�sVct(� )R�,pair( Upgrade( )Abandon( )
System located at /��/ X1/TC�I'
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: '7r9 - 7 Approved by _
H
t o/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)
I,
` �j" �p/' � / , hereby certify that the application for disposal works
construction permit signed by m �
e dated 7�43h� r , concerning the
property located at /70 6�� ��I w meets all of the
following criteria:
Y here are`no wetlands located within 100 feet of the proposed leaching facility
ere are no private wells within 1-0 feet of the proposed septic system
ere is no increase in flow and/or change in use proposed
There are no variances requested or needed.
+� If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the
proposed leaching facility will p.4.[be located less than fourteen (l a) feet above the maximum adjusted
groundwater table elevation.
Please complete the following: 6��z
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
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
t0/9/97
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)
[ i 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 wo feet of the proposed leaching facility
. There are no private wells within I: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^,eeded.
y . If the proposed leaching facility wiil�.,e located within=50 feet of anv wetlands,the bonom of the
proposed leaching facility will=oe:ocated'ess than fourteen(,I-')feet above the maximum adiusteq
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.-nap)
B)Observed Groundwater Table Elevation(according to Health Division we+.,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].
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