HomeMy WebLinkAbout0006 JOHNNY CAKE ROAD - Health UHNN Y CAKE RD. (CENT E ViLEE-
L=210-039
Omrford, NO. 1521/3 ORA
;;;; 10%
ru
U1
a 1 0 F F I C I A LUE
O Postage $
U—
Ln Certified Fee !
CO ! °'Po k
Return Receipt Fee �j F►e�
M (Endorsement Required) /3s
ORestricted Delivery Fee
C3 (Endorsement Required)
f
t7 Total Postage&Fees
.-XI Sent To
N
e
pt,Apt.No. or PO Bo o.
State,ZIP+4 -
r
PS Form 800 May 2000
Certified Mail Provides: 'N,i
o A mailing receipt
o A unique identifier for your mailpiece
o A signature upon delivery
o A record of delivery kept by the Postal Service for two years
Important Reminders.
• Certified Mail may ONLY be combined with First-Class Mail or Priority Mail.
o Certified Mail is not.available for any class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please'consider Insured or Registered Mail.
o For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811�to the article'and add applicable postage to cover the i
fee.Endorse mailpiece `Return Receipt Requested".To receive a fee waiver for i
a duplicate return receipt,a USPS postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,May 2000(Reverse) 102595-99-M-2087
L C/���
oF1ME rq,,, Town of Barnstable
Regulatory Services
* snxxsrnaLE,
v MASS. g Thomas F.Geiler,Director
�ArEn�. 60 Public Health Division PThomas McKean Director " oY
367 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
June 15, 2001
Robert H. Cox, Jr., Trustee
Annabelle Realty Trust
6 Johnny Cake Road
Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE
ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE
SUBSURFACE DISPOSAL OF SANITARY SEWAGE.
The property owned by you located at 6 Johnny Cake Road, Centerville, listed as Parcel 39 on
Assessor's Map 210 was inspected on June 4, 2001 by James M. Ford, private septic inspector, as
part of a property transfer. The following violation of 310 CMR 15.00, the State
Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary
Sewage was observed:
REGULATION 310 CMR 15.354
A single abandoned cesspool was observed by the inspector.
1) You are directed to hire a licensed Disposal Works Installer to properly abandon the cesspool
by either removing the cesspool or filling with clean sandwithin seven (7) days of receipt of this
letter.
2) The licensed septic installer shall obtain an abandonment permit from-the Health Division
prior to performing the.work. The cesspool shall be pumped by a licensed septage hauler, if
necessary.
You may request a hearing before the Board of Health if written petition requesting same is
received within seven (7) days after the date the order is served.
Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with an
order shall constitu separate violation.
PER ORDER OF TH BOARD OF HEALTH
as Mc can
Director of Public Health
q:/health/wpdocs/orderlet/gl en/cox
gyyF�htl ap°Pare 210039 1=n Ownerr
%cel,id 2 039 �i�ei=Q�� V Apit�Na 001296 are t� 0000000
rr ' `a / We�ghbdrhpod, '42AC r
De el t LOT 50 rGw i a 'SI 0.19 Acres �o
COX, ROBERT H JR TRS r eta ass - 101 `\
ANNABELLE REALTY TRUST______rr isrr 1 Ar a' 00001352 \�` �o
F 6 JOHNNYCAKE RD ,� �earA` dde ., 00
CENTERVILLE 02632 MA r
se a acc, 00 0000 000
arsx��re rim ':'�'". �"" ,> , � r .., .. ��� � � _ � __a �,.,,,•� ', � �� \�\;� .
v.
be®tl�ate 090187 Re erence 5913 275
j;
anu ry t COX ROBERT H JR TRS
ed' 0 7
lus§ i.antl: " 000031600 ui ding 000095600ea re 0000000500
JOHNNY CAKE ROAD Boa inex 0804 � rntc 0094
r e bi t CO !�/%gNNABLE POINT ROAD Sec Index 0032tg 0095 � ��
N
y�3 u t "s•Y 1� � �
,:Hat r .`� r '� « � � .3 '`•� « �,: ... " l ;
• o
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: o Johnny Cane Road
Centerville, MA 02632
Owner's Name: Bob Cox
Owner's Address: Same
Date of Inspection: June 4, 2001 RECEIVED
Name of Inspector:(Please Print) James M. Ford
Company Name: .lames M. Ford JUN 14 2001
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049 TOWN OF BARNSTABLE
Telephone Number: (508) 862-9400 HEALTH DEPT.'
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 the inspection. The 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
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
N s urther Evaluation by the Local Approving Authority
Fa is
Inspector's Signature: Date: June 6, 2001
The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original,should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority..
Notes and Comments
**.**This.report only describes conditions at.the time of inspection and under the conditions of use at that
time. This inspection does not address how the.system will perform in the future under the same or different
conditions of use:
a
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6 Johnny Cake Road
Centerville. MA
Owner: Bob Cox
Date of Inspection: June 4, 2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. 'System Conditionally Passes:
One or more system components as described in the Conditional Pass section need to be replaced or
repaired. The system;upon,completion of the replacement or repair,as approved by the Board of Health,will pass.
i
Answer yes,no or not determined.(Y,N,ND)in the for the following statements. If"not.determined",please
explain.
The septic tank is metal and over.20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution bux due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
-_- The.system required pumping more than 4 times a year due to broken or obstructed pipe(s).'The system will
-. ...._pass.inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6 Johnny Cake Road
Centerville. MA _ . ....
Owner: Bob Cox
Date of Inspection: June 4, 2001
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 C1VIR 15.303(1)(b)that the
system is not functioning in a marine:which will protect public health;safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(arid Public Water Supplier,,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS'is within:100 feet.of a
surface water supply or tributary to a surface water supply.
.The system has a septic tank and SAS and the SAS is within a Zone 1 of•a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for.coliform
bacteria 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,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
i
3
Page 4 of I 1 ,
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6 Johnny Cake Road
Centerville. AM - _
Owner: Bob Cox
Date of Inspection: June 4, 2001
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
_ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters 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'/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 SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a-Zone 1 of a public well.. .
_ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 1 OQ feet but greater.than 50;feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. .I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 6 Johnny Cake Road
Centerville. MA
Owner: Bob Cox
Date of Inspection: June 4, 2001
Check if the following have been done: You must indicate"yes or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
n/a Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?.
`✓' 'Writhe site inspected for signs of break out,.?
✓ Were all system components;excluding.the SAS,,located on site? :.
t Were the septic tank manholes uncovered,opened,and the interior of the.tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
fhe size and location' of the Soil Absorp#ra.System(S AS)on the site has been deterrn.^ed based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
,�' a?��'�-�%ties,r,'�''4➢° a'� ,� : 1
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
: .SYSTEM"INFORMATION
Property Address: 6 Johnny Cake Road j
Centerville. MA
Owner: Bob Cox
Date of Inspection: June 4, 2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2000- 75 000 gals.: 1999- 70,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310.CMR 15..203): gpd
Basis of design.flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): No
If pumped:
es.volume _ gallons--How was quantity pumped determined?
y
Reason for pumping: The owner was having the system pumped later in the day.
TYPE OF SYSTEM
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)
Innovative/Alternative technology. Attach a copyof the current operation and maintenance contract:(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval ,.
Other(describe)' s._..
- Approximate age of all components,date installed,(if known).and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
i
Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6 Johnny Cake Road—-
Centerville, MA
Owner: Bob Cox _
Date of Inspection: June 4, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line
Comments(on condition ofjoints,venting,evidence of leakage,etc.):
SEPTIC TANK: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age:- -Is age confirmed.by.a.Certificate.of.Compliance(yes.orno):. (attach a copy of
certificate)
Dimensions:
Sludge depth: '
Distance from top of sludge to bottom of outlet tee or baffle:.
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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
( pumping al integrity,liquid,levels
Commentsate of t(onrecommendations,. and outlet tee or baffle condition,structur
as related to outlet invert,evidence of leakage,etc.):
7
1 j xx Divx kXs
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
'SYSTEM-INFORMATION (continued)
Property Address: 6 Johnny Cake Road
Centerville. MA
Owner: Bob Cox
Date of Inspection: June 4, 2001
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
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:, None (if present.must be opened)(loca
te.on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no): _
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,SYSTEM INFORMATION (continued)
Property Address: 6 Johnny Cake Road.---
Centerville, MA
Owner: Bob Cox
Date of Inspection: June 4, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
" .- � -Inhovativelalternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
r;!i
The leaching pit had Y ofwater on the'bottom' The'scum Tine was'at the'same level There were no signs offailure. a cover
was 2'below grade The bottom to grade was approximately 8.
CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: I with leach pit
Depth-top of liquid to inlet invert: --
Depth of solids layer: Approx. 3'
Depth of scum layer: Same
Dimensions of cesspool: 5'W x S'T
Materials.of constriction: Block _.
Indication of groundwater inflow(yes or no): No
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
The scum/solids were Y thick and liquid was up to the outlet pipe The outlet tee was present The cover was 20"below grade.
The bottom to grade was approximately 8'.
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
r'
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
SYSTEM•INFORMATION(continued)
Property Address: 6 Johnny Cake Road
Centerville, MA
Owner: Bob Cox
Date of Inspection: June 4, 2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
C3A�k .
O Pee-,
C�ssPw
.Glriv�a/
a �
Al - 3 ,
a I - a�
Aa- as
10
Page 11 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 Johnny Cake Road....
Centerville. AM
Owner: Bob Cox
Date of Inspection: June 4, 2001
SPTE EXAM
Slope
Surface water
Check cellar
Shallow wells
i
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom ofthe pit to grade was approximately 8' Using the Barnstable topoQralihic'map'and the Cape Cod Commission water
contours map the maps were showing approximately 18'+/-to groundwater at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,
either expressed, written or implied, relating to the system, the inspection and/or this report.
11
_ TOWN OF BAR.NSTABLE
LOCATION �QhAntj CA 2. SEWAGE #
VILLAGE (2tett o"V'I ASSESSOR'S MAP & LOT-_11L' n7
INSTALLER'S NAME&PHONE�NO..
SEPTIC TANK CAPACITY S P cm
LEACHING FACILrrY: (type) 1 r _ (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER ",_901n OX
PERMITDATE- -COMPLIANCE DATE:�
Separation Distance Between the:
Maximur.rL 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 -
1
6Ac.�
a '
Al- 30
• ;LS ,
3.7