HomeMy WebLinkAbout0052 JOAN ROAD - Health 52 JOAN ROAD, CENTERVILLE
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COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFF�AlI,S
" DEPARTMENT OF ENVIR NMENTAI, ROTE ON
C
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
19, -1
AUG g 1
1-1,4 OF BAM'3TABLE
W ILLIAM F.WELD C
Governor TRUDY CORE
r i
Secretary
ARGEO PAUL CELLUCCI
41 l p r, ��F 4 F+�� DAVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address. 52 Joan Rd, Centervil'le,MA
Gary Mason
P rh' ,���� � � Address of Owner: 40 Janes Way
Date of Inspection: (If different) Bridgewater, MA 02324
Name of Inspector: WM E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: WM E Robinson Septic Servir.
Mailing Address: PO Box 1089 , C rt er ri 1 1 p., MA 02632
Telephone Number; 5 0 8 ` 7 7 5—8 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of 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
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: AI Date: u<
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY: Check A, B, C, Or D:
Al SYSTEM PASSES:
7 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
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.
Indic a 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 conforming septic tank
/`J as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:ltwww.magnet.state.ma.usldep
e'j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 52 Joan•tRd Centerville
Owner: Mason
Date of Inspect ion:
B] SYSTEM CONDITIONALLY PASSES (continued)
_ 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). Describe observations:
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
C] FURT R EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions 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.
7
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) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
TH SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
EN RONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to 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) OT ER
(zevieed 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 52 Joan Rd, 'Centerville
Owner: Mason
Date of Inspection: S-9
D] SYSTEM FAILS:
You must indicate ei;!,er "Yes" or "No" as to each of the following:
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
he failure.
Yes o
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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) LARGE SYSTEM FAILS:
You must ndicate either "Yes" or "No" as to each of the following:
e following criteria apply to large systems in addition to the criteria above:
T e system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
p blic health and safety and the environment because one or more of the following conditions exist:
Yes N
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)
The own or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requireme !ts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST ,
Property Address: 52 Joan Rd, Centerville
Owner: Mason
Date of Inspection: 'o2g 9
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.
V _ As built plans have been obtained and examined. Note if they are not available with N/A.
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.
v _ 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:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
1 _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)J
(revised 04/25/97) page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 52 Joan Rd, Centerville
Owner: Mason
Date of Inspection: 7-;L!r— 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: . 6-0 p.d./bedroom for S.A.S.
Number of bedrooms:_
Number of current residents:
Garbage grinder (yes or no):�U
Laundry connected to system (yes or no):y�6�s
Seasonal use (yes or no):/,
Water meter readings, if available (last two (2) year usage (gpd): 1996 — 87 , 000g
Sump Pump (yes or no):/L y 1997 — 78, 000g
Last date of occupancy: '
COMMERCIAL/INDUSTRIAL:
Type f establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industri I Waste Holding Tank present: (yes or no)_
Non-sa iitary waste discharged to the Title 5 system: (yes or no)_
Water ineter readings, if available:
Last d e of occupancy:
OTH escribe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECO)tDS a source of information:
/J
System pumped as part of inspection: (yes or no)lS
L`
If yes, volume pumped:l�S� gallons 7�
Reason for pumping: Alto 6oLl '.
TYPE OVYSTEM
_iz 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. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 2-9 9 D— [!�
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 52 Joan Rd, Centerville
Owner: Mason
Date of Inspection: ;1,29 9,F
BUILDING SEWER:
(Locat on site plan)
Depth low grade:
Materia of construction: _cast iron _40 PVC_other (explain)
Dista ce from private water supply well or suction line
Diam er
Comm nts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on bite plan)
Depth below grade: /
Material of.construction: _✓concrete _metal _Fiberglass _Polyethylene —Other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: 6" �d
Sludge depth: e19 t +
Distance from top of sludge to bottom of outlet tee or baffler
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:lLl
How dimensions were determined:/�L-L✓ '- 1�
Comments:
(recommendation for pumping, condition of inlet and outlet tees eo baffles depth of liquid level in relation to outlet invert, structural
integrity, evidence of I kage, etc.) /�6 ® i��p- —V o•� �P la �.�•= ,6�" D�"�c� �''��
r✓TG,e 7
GREAS TRAP:
(locate n site plan)
Depth low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensi ns:
Scum t ickness:
Distan from top of scum to top of outlet tee or baffle:
Distan from bottom of scum to bottom of outlet tee or baffle:
Date of I st 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,, idence of leakage, etc.)
g
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 52 Joan Rd, Centerville
Owner: Mason
Date of Inspection: 7—A v 5�
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth low grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Di 'ensi ns:
Capaci : gallons
Design flow: gallons/day
Alar level: Alarm in working order_Yes; _ No
Date o revious pumping:
Commen s:
(conditio 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 carryover, !yidence of leakage into or out of box, etc.)
PUMP HAMBER:
(locate n site plan)
Pumps n working order: (Yes or No)
Alarm in working order (Yes or No)
Com nts:
(note co dition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 52 Joan Rd, Centerville
Owner: Mason
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_✓
(locate on site plan, if possible;_excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs off hydraulic fail e, leve of p nding, condition of vegetation, etc.)
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet inve
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Commen
(note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Material of construction: Dimensions:
Depth o solids:
Commen s:
(note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 52 Joan Rd, Centerville
Owner: Mason
Date of Inspection:
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)
1
f
G>�
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 52 Joan Rd,Centerville
Owner: Mason
Date of Inspection:
4-
Depth to Groundwater )a' Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
"bservation
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
Use USGS Data
'1
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
4
(revised 04/2S/97) Page 10 of 10
No. ' 7 S70 Fee$5 0 .0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppYication for Mq;ponl 6p5tem Comaruction Vertu
Application for a Permit to Construct( )Repair(x�'-)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 52 Joan Rd Owner's Name,Address and Tel.No. 6 9 7—6 3 6 4
Assessor'sMap/Parcel Centerville Gary Mason 40 Janes Way
�2 (9-0-77 Bridgewater, MA 02324
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Sry
P 0 Box 1089 Centerville MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
Other Type of Building 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 Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consisting
of 1500g tank, D—bx and three H2O maximizers. G-A/ Sd(�
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 t ' Bo d of Health.
Signed Date
Application Approved by e Date 7 /S—�
Application Disapproved for the following reasons
Permit No. 9 9= 4'S_d Date Issued 7 —/�
f
6"rA,
I
TOWN OF BARNSTABLE -- ----
LOCATION J /
SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT 2
INSTALLER'S NAME&PHONE NO. /�A,� jii. ,1 y �;g 77
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /7'
�'� �, ? (size) •���,NO. OF BEDROOMS_
BUILDER OR OWNER
PERMTTDATE: —/.�- a COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of LeachingPrivate Water Supply Well and Leachin Facili Feet
on site or within 200 feet of leaching facility) any we
Edge of Wetland and Leaching Facility(If any wetlands ezi Feet
within 300 feet of leaching facility)
Furnished by
.. .. ...�-.� \r ' ..i...r�1� r..,�f"^{MiyylY•..�1"rMYKYJMhsr.f'N+._�r Y....�r.T w�.M.iw'q'wi,•�r..Mwr... .w.w+L'I.�YW�MA'Arn.w'Ri.M'.l�Mi'..r r....MPi'^r tla].'V"' .,.v'°`^eMy". ,_ m...... .. �
jc
No. U ' 7S?.7 11A Fee$50.00 /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Yes
ZIpprication for Mfgozal *pgtem Construction j3ermit
Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components'
Location Address or Lot No. 5 2 Joan Rd Owner's Name,Address and Tel.No. 6 9 ]—6 3 6 4
O,"
�ss4sgor'sMap/Parcel Centerville Gary Mason 40 Janes Way
Z 2 &Q'17, / Bridgewater, MA 02324
Inst 11 Name,Address,and Tel. o. 7 _8�`lt t ysigne;r'� dress and Tel.No.
W E Robinson Septic ' ry V
P O Box 1089 Centerville MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. L Garbage Grinder(no)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per da?'��ai'c lafed daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title i System consisting
of 1500a tank D—bx and three H2O maximizers. /yam
Date last inspected: r
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 thi BopA of Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 9 _L/ Date Issued .
f
THEVOMMRNWEALTH OF MASSACHUSETTS t
/ r
TABLE, MASSACHUSETTS
Mason i e Of COrttfiance ;
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired(XX) Upgraded( )
Abandoned( )by
at 52 Joan Rd Centerville has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. -AKTO dated 7
Installer W ERObinson Septic Sry Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date `7 . 1 9 . 141:? Inspector
s\s , V
———————————————— ——— — — ———— ——
No.
Fee QQQQ
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mason MwigPogal *pgtem Construction permit
Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( )
System located at 52 JnanRd
Centerville
Installer W E Robinson Septic Sry
and as described in the above Application for Disposat._System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special condiitbns-:-'
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved b0.cc _ % �
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)
pn) 6
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 52 Joan Road, Centerville, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 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 facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the 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 Evaluation(according to Health Division well map)
SIGNED: DATE '� f
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of-6e proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted)'',
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Zen��i
TOWN OF BARNSTABLE > G
LOCATION XoZ J6 ed A, &Z SEWAGE #
VILLAGE Z"^- / ZIS 1����` ASSESSOR'S MAP & LOT 2'Z S? - -7�2
INSTALLER'S NAME&PHONE NO. I di �t-„a — Ste 7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /yn�® �'�� 6°r f (size —1�21
NO.OF BEDROOMS
BUILDER OR OWNER ����°S 0 �
PERMITDATE: 2—/J l L COMPLIANCE DATE: ��9
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Le aching Facil' Feet
Private Water Supply Well and Leaching Facility (If any wells e
on�site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exi
within 300 feet of leaching facility) Feet
Furnished by
� � 6.2 1 �. l