HomeMy WebLinkAbout0404 OLD STAGE ROAD - Health 404 OLD STAGE RD., CENTERVILLE
A=190.112
SlII cv"�0�o
No 2-53 OR
HASTINGS,MN
C0%1'�%ION"EALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTI
ONE WINTER STREET, BOSTON D29 0210E (617) 292-5500
T
Susan Hobbs TRLDY . OXE
��4 Sic tan
ARGEO PAUL CELLUCCI � i�, S I���'ID B. S UHS
Governor �� 9 Cornaus Toner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR �`'�Yay 9 +�
PART A �'j
CERTIFICATION
Property Address: 404 Old. Stage Rd.. , Name of0 Susan Hobbs
Centerville ,Qville , MA Address of owner: Ave . ,
Date of Inspection: .7--f ! C1 l
Name of Inspector:(Please Print) [Uy t eta D .S a J, J
am a D%reTo�s"tt U U 111S 01«l e p L�C erV of Title 5(310 CMR 15.000)
Company Name: vu
Mailing Address: Box 1089, Centerv! e , MA
Telephone Number: 7 7 5—8 7 7
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 Of
Inspector's Signature: 1 Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
i• Pr.nted on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'ropertyAddress: 404 old. Stage Rd.. , Centerville . ,MA
Jwner: Susan Hobbs
Date of Inspection:.2-0-g `.
INSPECTION SUMMARY: Check(A,J A C, o/ D:
A. PASSES:
t77ave not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
r"
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.
Indicat yes, no, or not determined(Y, N, or NO). Describe basis of determination,in all'instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 404 Old. Stage Rd.. , Centerville , MA
Owner. Susan Hobbs
Date of Inspection:1-9-/
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.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) THER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property AddreAs: 404 Old. Stage Rd.. , Ceriterville , MA ` '
Owner: JUsan Hobbs
Date of Inspection:2—41..7
D. SYSTEM FAILS:
You st indicate either "Yes" or "No to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
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. LA E SYSTEM FAILS:
You mu indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public
water supply well)
The ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office o the Department for further information.
revised 9/2/98 Page 4of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
404 Old. Stage Rd.. , Centerville, MA
Property Adt*tN an Hobbs
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No/
Y 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"trmal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
/ inspection. '
L1 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.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
/ [15.302(3)(b)]
V - _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenawoo-0f
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Itop"Address: 404 Old. Stage Rd.. , Centerville , MA
Owner: Susan Hobbs
Date of Inspection:v; 9 7 1
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms(design): 3 Number of bedrooms (actual):3
Total DESIGN flow 9,5-
Number of current residents: 0
Garbage grinder(yes or no): 4— 0
Laundry(separate system) (yes or no):dz); If yes, separate.inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): /� O
Water meter readings, if available (last two year's usage(gpd): 1998 6, 000 gal.
Sump Pump (yes or no):%L D 1997 26, 000 gal.
Last date of occupancy:a
COMMERCIAL/INDUSTRIAL:
Type o establishment:
Design low: qpd ( Based on 15.203)
Basis of esign flow
Grease t ap present: (yes or no)_
Industri Waste Holding Tank present: (yes or no)_
Non-s itary waste discharged to the Title 5 system: (yes or no)_
Wate meter readings, if available:
Last a of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) JL C
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
_Ll Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no),Z,._o
III
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 404 Old. Stage Rd.. , Centerville , MA '
Owner: Susan Hobbs
Date of Inspection:
B ILDING SEWER:
(I ate on site plan)
Dept below grade:_
Mate ial of construction:_cast iron_40 PVC_other(explain)
Dis nce from private water supply well or suction line
Di eter
Co ments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grader
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age---� Is.age confirmed by Certificate of Compliance_(Yes/No)
A I , 1
Dimensions:
Sludge depth:_ $ i
Distance from top of sludge to bottom of outlet tee or baffle:_
Scum thickness:_ ' 1
Distance from top of scum to top of outlet tee or baffler r ,
Distance from bottom of scum to bottom of outlet ter or baffle: /Y
How dimensions were determined: 0 P45 r'—
'omments:
(recommendation for pumping, condition of inI t and outlet tees or baffles, de th of liquid level in re l tion to outlet invert, structural integrity,
evidence of leakage, etc.) 6- eel• / w
0
G SE TRAP:
(loca a on site plan)
Depth below grade:_
Materi I of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dime ions:
Scum hickness:
Dista ce from top of scum to top of outlet tee or baffle:
Dista ce from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Co ments:
Ire mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evide ce of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'rop"Address: 4o4 Old.,'Stage Rd.. , Centerville , MA
OWE: Susan Hobbs `
Date of Inspection:
TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
Iota on site Ian)
( P
Depth below grade:_
Materi I of construction: _concrete_metal_Fiberglass_Polyethylene_other(explain)
Dime ions:
Capa it
gallons
Desi flow: gallons/day
Alar present
Alar level: Alarm in working order: Yes_ No_
Dot of previous pumping:
Co ments:
(c dition of inlet tee, condition of alarm and float switches, etc.)
I
DISTRIBUTION BOX:_V
(locate on site plan)
Depth of liquid level above outlet invert: d/
Comments:
(note if level and distribution is equal, evidence of s9lids carryover, evidence of leakage into or out of box, etc.) -
0 ✓�.[/ -
PUMP AMBER:_
(locate o site plan)
Pumps in orking order: (Yes or No)
Alarms in working order(Yes or No)
Common s:
(note co dition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
4op"Address: 404 Old. Stage Rd.. , Centerville , MA
Owner: Susan Hobbs
Date of Inspection: ^9�
SOIL ABSORPTION SYSTEM(SAS): (/
(locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydpraulic failure, level of ponding, damp soil,'cpnditi2p of vegetation etc.)
o
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: �) '
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
C o m n ts•.a
(note condition of soil, signs of hydraulic failure, level,of ponding, condition of vegetation, etc.)
PRI _
(local on site plan)
Mat ials of construction: Dimensions:
Dep h of solids:
Co ments:
(not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of_tf
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
"rop"Address:4'04 Old. Stage Rd.. , Centerville , 1V1A < .
owner: Susan Hobbs
Jate of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
U
d�
All
1
�f
m
4
revised 9/2/98 Page 10of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
rop"Address.404 Old. Stage Rd.. , Centerville. , MA
owner: Susan Hobbs
Date of Inspection: 4 7
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
.k
Estimated Depth to Groundwater )S Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
>// Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
JL"5 40`�� 1 g g
revised 9/2/98 Page 11of11
v.
OF
No. < o :il Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
4 Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0ppYication for ;Di-4po.5al *pe;tem Construction Permit
Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) L1 Complete System O Individual Components
Location Address or Lot No. age H d' ' Owner's Name,Address and Tel.No.
Centerville , MA Susan Hobbs
Assessor's Map/Parcel I � / 24� Norths id.e Ave . ,Lynn, MA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P.O . Box 1089, Centerville , MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
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) Inttallat ion- of a new Title 5 septic
system consistin of a 1 , 500 gal. an - ox, an . 2 precaslu
leach chambers .
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 th�Enironme ntal Co a and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this__,! a .
Signed Date
Application Approved by Date 1 '7 �T—
Application Disapproved for tqpfolloAg reasons
Permit No. 0 :2 Date Issued
h RY Y t
No. 0 / m ,... Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
01 pYication for �Digaal *p.5tem Construction Permit
c Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 404 uld. Stage Owner's Name Ad ss and Tel.No.
Centerville , MA Susan )Io `�bs
Assessor'sMap/Parcel / 24 Norths id.e Ave. ,Lynn, MA
t► ll
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P.O. Box 1089, Centerville , MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
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 app icable) Intallat ion Of anew Title 5 septic
system consistin of a 1 , 00 gal. an - o , and 2 precast
ieach cam ers.
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 En ' onmental Co e and not to place the system in operation until a Certifi-
r cate of Compliance has been issued by this and Heath. �y
Signed X4 Date
'Application Approved by a' Date
Application Disapproved for d9folloVing reasons
Permit No. - O Date Issued
———————————————
��"� THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Hobbs (Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewa a Di psal System Constructed( )Repaired(X )Upgraded( )
Wm. E . Robinson septic Syervice
Abaq Oil d( ld b� a e ,
at 4 4 p g r Centerville,e has been constructed in accordance
with the rp�visio ,of Ta�tle 5 and the for is o a s onstruction Permit No. O dated/--
Installer
p iss .K o b ins on epP U�.
Designer
The issuance of this permit shall not be construed as a guarantee that the sy�' w I funct*designed.
Date r 7 InspectorG_ �G��
----- ------
1 No. Fee
0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Hobbs Mi9;pog *`r_ Ial, IOem (tonotruction Permit
Permission is hereby g8Td6
5 oLSor�trtuact( pai n i�jel(le�Al don( )
System located at ✓,,
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: 7 po _
- - ! Z Approved by l
(
i
NOTICE: This Form Is To Be Used For The Repair Of Failed
Septic Systems Only.
� 9 � �- 1
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I,_William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated , T , concerning the
property located at 404 Old Stage Rd.,Centerville, MA meets all of the
following criteria:
* Z are no wetlands within 100 feet of the proposed leaching facility.
* ere are no private wells within 150 feet of the proposed septic system.
*�re 's 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 with 250 feet of any wetlands,the bottom of the
proposed leaching facility will�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) _V
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: y ��� DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
S
1 ISO "
TOWN OF BAR/N�STABLE
LOCATION 1/6 `/ (3/�./ -S /o� 7���1/ SEWAGE # Y � 7
, /
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 'S
-- S - - .
I^ LEACHING FACILITY: (type) � - (size) 1; '-
NO.OF BEDROOMS J' /
i BUILDER OR OWNER /1 2
PERMTT DATE —7—2 `7 COMPLIANCE DATE:,`',n—9
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 facilit�) Feet
Edge of Wetland and Leaching Facility (If afiy wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
( (
_ � z
J f
TOWN OF BARNSTABLE
LOCATION 4/ 13Id SEWAGE #
VILLAGE <f d`-` ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. tf� 1 %N g �— i t�" /
SEPTIC TANK CAPACITY .
LEACHING FACILITY: E; -'�'�`�' �—
(type) (size) /��'-�--
NO.OF BEDROOMS 3 /
BUILDER OR OWNER
PERMITDATE:f,,?—2 2 COMPLIANCE DATE:,;�=,-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Botto of Leaching Facility Feet
Private Water Supply Well and Leaching Facili. (If any wells exist
on site or within 200 feet of leaching faci ' ) Feet
Edge of Wetland and Leaching Facility(If a y wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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