HomeMy WebLinkAbout0057 SUMMERBELL AVENUE - Health 5 r SUMMERBELL AVE., CENTERVILLE
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UPC 17534
g No.2�R '`bsr.Coes'�
KASTINOS.UN
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I
DATE:�,_6/28100___
i'
PROPERTY ADDRESS:_�_;.__—__________
57 Summerbell Avenue____
_ Craigvilig_____________
On the above date, I Inspected the eeptlo ,system at the above address,
This system conslsts of the following:
1 . 2-6 ' x7 ' cesspools. 0
Based on my Inspection, I certify the following conditions:
2 . This is not a title five septic system. ( 78 Code )
3 . This is a sewage system. System consists of two 6 'X7 '
cesspools in series.Both cesspools are presently dry,.
4 . The sewage system is in proper working order at the
present time.
SIGNATURE: ./
• 61I
Company: o
Jose•Ph_t Hecmber_& Son , Inc .
� �
Address:__Box 66 -------- �ECEtvED �
0
__Centerville L Har_02632-00664, JUL 13 200o
Phone 508_775_3398_______ i 11 ro cq
lee le
THIS CERTIFICATION .DOES NOT CONSTITUTe A QUARANTY OR WARRANTY ,.
a
JOSEPH P. MACOMBER & SON, INC-
Tank s-O
CfIssnpto
oli7-L7e a6chAf I
Zold$
Pumped L Installed
Town sswor Connictlons
P.O. Box 6775.3338erY1114, M 102632.0066
I
COMMONWEALTH OF MASSACHiUSET t
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE RANTER STREET, BOSTON MA 02108 (617) 292.6600
TRUDY CORE
. 3ecr+ta,ry
ARGEO PAUL CELLUCCI DAVM B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
P"*-y Ad&—: 57 Summerbell Avenue Nart,.of Ownw John Healy
Craigville Add.of 0wrw: 18 Wi nt'r-r Rt•raat-
Dats of lirispectio^, � / Sudbury, Ma. 01776
Name od for:tPs a Joseph P. Macomber Jr.
I sim a DEP epprvvW systwn inspector pursuant to Section 15.340 of 71do 5(310 CMR 15.000)
Compa,mmartw: Joseph P. Macomber & Son, Inc.
M &&Address: Sox bb , cenEerville, Ma. 02632-0066
Telephone Numbs — —
CERTIFICATION STATEaAENT
I certify that 1 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 end
maintenance of on-site sewage disposal systems. The system:
�y' Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails te Q
Da :
lnspecta•s Signature• /
The System Inspec r shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)w)tNn 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 oAEiivtronmerrad Protection. The original should'be sent tov"
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page IofII
01 Printed on It"Ied Papa
SUL3VRFAtX SEWAGE DISPOSAIL 5Y9TVA iNSI'£CTlON FOPJA
PART A
t COMFICAMN (06nd-014
J'roporryAddraas: 57 Summerbe .1 Avenue, Craigville
John . Healy
D.o or tr.apocr+Son: 6/2 8/0 0
P-43I-CT10N $UkAMAAY: Chock Al B, C, " Ot
A. SYSToj PASSES:
I have not found any information wNch Md)catos that any of th# 1juuo cordtom doscribed In 310 CMR 14,303 exlat. My it&
crhod not evaluated us Ind)cotod below,
Ca liILFNT S: Jy
1, STSTDA CONDMONAUY FAMES;
One w mwo system oompoflonu u do#wtbed In the 'Cortdxdonal ►"a' oeodon need to bo roplaood a ropaLed. The oyetim. vp
complodon of the ropieooment w repelr, w aPProwd by%ho Stud of Health, Will Pus,
"cote yoo, no, w not determined(Y, N. w ND). Domibo bails of dotarmMadwt to oil trtstanoss, If 'not dotarrrJnod', explain why rwt.
4.We The oepds tank le mow. urJeet the ownw w epwatw hw P(9v44dod tho #yotem Mape,me whh o oopy of a Oor""%# o
Compllonco fottoched)Indtodnp that the tuft was Mat&god wlWn twonty(20) youo PAor to tho dau of the tnepovvon
the oepdc tank, whothor or not motel, I° orookad, ovvovxdly unaovnd, Mow# wb°tandaJ tnNuedon w erNvedon. a
failure to Immlnont. The system will poet ktapection If the exl#dnp ospde tank I# ropissed with a ooenprytnti oeptfc wv
approvod by the {oard of Health.
Sewopo bockvp or brookout or Nph eudo water(rvel obsorvod M the dlsu(budon box Is duo to brokon w obovvcud pap
or dvo to a broken. tordod or uneven dlsuibvtJon box, The ►y#tom wW peae Vwpootlon If (whh app(ovaJ of Vte ioard of
Health).
broken pips(s) we replaced
obawcdon la removed
dJoutbvdon box le levelled w replaced
The synom ro4;k+kod pvmokirrnaro d►art'iourdrnoa•yeu•due to brollonvr vf>otrvoted pipo(s). Thom wW—Pgaw^
Inapecoon If (with opprovai of the fowl of Health):
broken pipe(#) u#toplacid
obswcdon la removed
revised 9/2/98 P►�r=erIt
t ' SUBSURFACE SEWAGE DISPOSAL SYSTEMiINSPECTIiDN FORM '.
PART A
CERTIFICATION (con*wed)
Pmpwty Address: 57 Summerbell Avenue, Craigville
Owrw: John Healy
Dat'of kupecton: 6/2 8/0 0
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 tong to protect the
public health, salary and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.WIL.L.PRQTECT THE PUBLIC HEALTItAND SAFETY AUD THE 0j1080NM89Tr
Z 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)1DETERM0a3 THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVtRONM&fT:
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 soll absorption system and the SAS Is wltNn a Zone I of a public water supply weU.
The system has a septic tank and soil absorption system and the SAS Is within 60 feet of a privets water supply wall•
The system has a septic tank and soil absorption system and the SAS Is less then 100 feet but 60 feet of more from a
privets water supply well, unless a well water analysis for collform bacteria and volatile organic compounds Indicates that OW
well Is free from pollution from that facility and the presence of ammonia nitrogen and rtluste nitrogen Is equal to or less
than 5 ppm. Method used to determine distance •A//f (approxlmrdon not vaUd).-
31 OTHER
revised 9/2/98 PaQt3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
PART A
CERTIFICATION (con"*d) r
Property Addrsss: 57 Summerbell Avenue, Craigville
Owner: John Healy
Date of lnspOctiOn: 6/2 8/0 0
D. SYSTEM FAILS:
You must Indicate either 'Yes' or 'No' to each of the following:
folI have determined hat Identified or more
The Boardlof Healthowing lshouldure nbadcontactad to deterons exist as mine what whatOwllllb•rt•cassuy to conact the faitur
determination Is
Yes No,r $A$-0r-cesspod, -
�/ Backup o}eewage i^toiaciNty'°r•^*t+�+oomponertt�daeQo em over4o�ded or�iogg�d
f the ground or surface waters due to an overloaded or dogged SAS or
Discharge or ponding of effluent to the surface o
cesspool.
AjA/e S'tatic liquid level In the distribu Ion box above outiet.invert due to an overloaded or clogged SAS or cesspool.
C.Llas 5 4A!dry)
Liquid depth In cesspool Is less than 6' below Invert or available volume is less than 112 day flow.
Required pumping more than 4 times In the last Year 11U due to clogged or obstructed plps(s).
Number of times pumped-L•
— 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 fast 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 60 lest of a private water supply wall,
Any portion of a cesspool or privy is less then 100 feet but greater then 60 feet from a private water supply walld to be with ^°
acceptable water quality
tt analysis.
sorganiocIf the well has
has been
a analyze
nitroflen end nitrate nitrogen.
I- copy of well water analysis for
.�coliform
I- LARGE SYSTEM FAILS:
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:
e s stem is a NgnlAcant ttueat to F
The system serves &
health and safety and f the ilenvironment because one orty with a design flow of 0 more 00 pofthe follod or wing rconditions exisge System) ant: Y
Yes No/
�/ the system Is within 400 feet of a surface drinking water supply
the system•Is-within 200 {Ntof•+Nuwts(y�o�aurfau,drk>klwqw+
Nr su►PIY ... .
the system Is located In a nitrogen sensitive area(interim Wellhead Protection Area:IWPA) or a mapped Zone II of a pu
'—' water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 16.304(21. Please consult the local regi
otfice of the Department for further Inforpstlon.
Psee 1 of 11
revised 9/2/98
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
i r PART B 1 '
CHECKLIST
Property Address: 57 Summerbelle Avenue
Owrw: John Healy
Data of inap.ction: 6/2 8/0 0
Check If the following have been dons: You must Indicate either 'Yss' or 'No' as to each of the following:
Yes No i
Pumping Information was provided by the owner, occupant, or Board of Health.
-Non*of the systemcompoawAa haw:baan pan4*d4opatJeaat two•wwke aa4.tbe7ystam h"A wowcolaiogw.d Ao%
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
Inspection.
As built plans have been obtained and exemlned. Note If they are not available wl N/
_ The facility or dwelling was Inspected for signs of sewage back-up.
The system does not receive non•senitary or Industrial waste flow,
_ The ske was Inspected for signs of breakout.
_ All system components,ei cluding the Soil Absorption System, have been located on the sits.
_,L1C4YC_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffle
or less, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum,
The site and location of the Soil Absorption System orr 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 unacceptabaei
116.302(3)(b))
_ The facility owner Lad. p nU,Jf dittarar t froar.oasrnarl.+scara.prautdad,wlth l^+prra"oaon?hA p•npar m,IQt•^ ^f
SubSurface Disposal Systems.
revised 9/2/98 Nile sorit
a { SUBSURFACE SEWAGE DISPOSAL SYSTfJA WSPEICTION FORM ,
PART C
SYSTEM INFORMATION
Prey Ad&@": 57 Summerbell Avenue
Owi1 -. John Healy
Dou of lnap.ctson. 6/2 8/0 0
FLOW CONDITIONS
RESIDEINT111L:
Design flow: uD g•p•d./bedro m.
Number of bedrooms deal )' Number of bedrooms(actual):1
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) ( as or&_: If yes, sspuaislnspactlon•required
Laundry system Inspected ye no) �L4S../Q0® a /0) S G u19•D•
Seasonal use (yes or no): t✓
Water meter readings,If sva table (last two year's usage lgpd): = �� 6n ' , �� 64. "
Sump Pump (yes or no):
Last date of occupancy: /"---
CommE3iCtAL/W DUSTRl/1L:
Type of establishment:
Design flow: ollvf ood I Based on 16.203)
Basis of design flow AIA
Gress#trap present: (yes or no
Industrial Waste Holding Tank present: (yes or WAY
Non•senhary waste discharged to the TItJe 6 system: (yes or no),&
Water meter readings,If available:
Last date of occupancy:
OTHER:(Describe)
Lest data of occupancy:
' GENERAL INFORMATION
PUMPWG R ORDS +yqd to rc�oj Information:
System pumpiid as pan of Inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
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)
IIA Technology !II. Attach copy of up to date opersdon and maintenance contract
Tight Tank t71T Copy of DEP Approval
Other
APPROXIMATE AGE of*11 components, date Installedilf known)-end souroe o44wformatlon:
Sewage odors detected when•arrlving at the site: (yes or no)t&
revised 9/2/98 Page 6ofII
Macomber Customer History Screen 6/2812W0
4 \
� Customer number 3950 \
Create New Invoice
Company Name
Customer Name John Healy MO Find Invoice
JobAddress 57 Summerbell Ave
JobCity craiaville Find Customer
JobState MA Add Billing Address
Jobzip
Tel Print History
Fax Customer List
Billing Address 18 Winter St
BillingCity Sudbury Print
BillingBtate MA
BillingZip 01776
Notes 78--87
6/2188 pump 1 65.00 snake 35.00 7t6188
WOO SC 35.00 6125190
Z11/96 pump 1 pool 145.00 7116t96
Z17/96 replace houseline 240.00 7/26196
611/00 pump 1 p goo 145 00 615100
i
1
k /
ry
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SUBSURFACE SEWAGE DISPOSACSYSTEM INSPECTION FORM
r PART C I 3
SYSTEM INFORMATION(coftdr%md)
PropwtyAddresa: 57 Summerbell Avenue, Craigville
D`Mi1 : John Healy
Dou of k`apecdon` 6/2 8/0 0
BUILDING SEWER:
(locate on site plan)
a
Depth below grads:
Material of construction: cast Iron 4 PVC other (explain)
Distance fror private water supply well or suctl n line'
Diameter '
Comments: (condition of joints, venting, avidonce of
11
s&nC TANK
(locate on she plan)
Depth below grsdo:
Material of construcdon:� concrete,amet&14&Fiberplass,t&Polyethylene�othar(axplain)
AM 4/0
If tank Is instal, list age Js.ago.conrwmod by Cert)ffcats of Compliance (Yes/No)
Dimensions:
Sludge depth: IVA -
Distance from top of sludge to bottom of outlet toe orbaffle:_/)?
Scum tNckness:_ q
Distance hom top of scum to top of outlet too or baffle: IVQ
Distance from bottom of scum to bottom of outlet is* or baffle:_
How dimensions were determined: AJl9
Comments:
(recommondation for pumping, condition of Inlet and outlet teas or-baffles, depth of liquid level In relation to outlet invert, atructursl integrity.
evidence of leakage, etc.)
�.�.
GREASE TRAP:
(locate on site plan)
Depth below grader
Material of construction:4-�iconcrets4dmotaL(AFiberglasLo�±Polyethylon@4dfother(explain)
Dimensions:
Scum thickness: Ay
Distance from top of scum to top of outlet too or bafflo: &, •
Distance hom bottom of scum to bottom of outlet too or.baffio:-49-
Date of lost pumping:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level In relation to outlet Invert, structural Intogrity.
evidence of leakage, etc.)
revised 9/2/98 Page 7orII
i
SUBSURFACE SEWAGE MSPOSAL SYSTEM W31PECTION FORr~A
PARTrC +
SYSTU4 WFORAAAnON (condrtueQ)
f'°pwTy Addre": 57 Summerbell Avenue, Craigville
Derve cd v4pocd, : John Healy
6/28/00
TIGHT OR HOLDWG TANK/hairy. (Tank must be pumped prior to, or at time of, Inspection)
(locals on site plan)
Depth below graft.&
Material of consvvction:4;Aconcrett4(g,motal{rq Fib*rplrasfl4a PolysthylanoAg-cther(axpl&ln)
_ AM
Dlmenslons; AIA
Capaclty: AM gallons
Design Row:A_ gallons/day
Alarm present_ AM
Alarm level:_ AM Alarm In working order:Yss f. N9410
Oste of previous pumping: AVA
Comments:
fcondltlon of Inlet tee, condition of alarm and float switches, etc.)
Aw/ 4 Rre .77- ho 4p�lT
DISTRIBUTION BOX:d&Ae
Rotate on site plan)
Oeptn of liquid level above outlet Invert:__
Comments:
(nr i If level and distributionIs equal, evidenoe of solids carryover, wldenee of leakage Into or owl of teoz,
,1�Tri L�3 .t /�/Y /S w/dT1JI';jO9sbc/T
PUMP CHAMBER:Ad�ve.
(locate on site plan)
Pumps In working order; (Yes or No)_ f
Alarms in working order (Yes of No)—AA
Comments:
mots condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 eof11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA
PART C
SYSTEM INFORMATION fcontirx»d)
Pm9w y Ad&*": 57 Summerbell Avenue, Craigville
OwT1e : John Healy
oet.of Insp.ctton:
6 2$��yy��O,,0,,
SOIL ABSORPTION SYSTEM(SAS) /J [U7.Y1v�
(locate on site plan, If possible; excavation not required,location may be approximated by non4ntrusive methods)
If not located, explain;
Type:
leaching pits, number:
latching chambers, number:0
leaching galleries, number:
leaching trenches,number, length:
latching fields, number, dims Ions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
1 ote condition of soil, signs of hydrau c fall re, level pf ponding, dam soli, c ndition'pf vegetation, etc.)4.
CESSPOOLS:
(locate on slit plan)
Number and configuration: —
Depth-top of liquid to Inlet Invert:
Depth of solids layer: ULU
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Infl w (cesspo must be pum ed as part of Inspectlon)
Comments:
inoLkcondidon of *oil, 81grt�of hydraulic failure, level of ponding,,condit)on of-vegetation, etc.)
PRIVY:��
(locate on site plan)
Materials of construction: led Dimensions: y�
Depth of soiids:_&A
Commenu:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc,)
revised 9/2/98 PBee9of11
SU63VR/ACt SEWAGE DISPOSAL 9Y9TVA tNXP9C'nON POP"
SYSTEM W!'0R3d =N(Cor+dro.W4
ptopeMAdd 57 Summerbell, Avenue, Craigville
owrow; John Healy
Dou or v4p.adon: 6/2 8/0 0
$U7CH Of SEWAGE DISPOSAL SYSTEM:
IncJvd# dqr to •t Iq&rt two perm&nent reference landmuki or bonthmuks
loc+19 ►tl well, wlWn 100' (Locate where publlo wet*(wpply comes Into Was)
57 sv i 8z Il RvC L'r� v,'((�
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F
17) �1ZJ
revised 9/2/98 hcoloof11
SUBSURFACE SEWAGE DtSPQSAL SYSTDA INSPECTION FORM
PART C iP
SYSTE)A pr-oRMATION it-,drx-di
Pt•opw y Address: 57 Summerbell Avenue, Craigville
Dw"er: John Healy
Dau of lnape.Ction: 6/2 8/0 0
NRCS Report name
soil Type_
Typical depth to groundwater
USOS Date webslts visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Caller
Shallow wells
E►timeted Depth to Groundwater_Feet
Piesse Indicate ail the methods used to determine High Groundwater Elevation:
Obtained hom Design Pis
na on record
Observed Sits (Abutting prop• y, bservation hole. basemeat sump etc.)
Ostarminad from Iocsl conditions
Chocked with local Board of health
Chocked FEMA Maps
hocked pumping records
hocked local excavators. Instsllare
Used USOS Data
Describe how you established the High Groundwater Elevation. (h[j be completed)
.,`,
revised 9/2/98 PacsItof11
� ' .+nmr.�nir��r'an►rww•��Tnwrw+.i•Rwnw•+ww►iw�ww�n�tiw•+�+�w�nw�ww.+���ww .rw-�-.-�-n.-. .• .- i
I'ONN OF BARNSTABLE WARD OF HEALTH �
SUIISURFAU SFHAOF, DI SNSAL SYSTF,M INSPECTION FORM PART D .- CERTIFICATION
^�n^...... -�.ne-.ar.+w+n�•wnn�w��+rn•w.r��a�.nww.�w�•���wrwewww�w�wr� ww +..•r.-••---•. -. 1
-TYPO OA PAINT Cl.6AALY-
PROPERTY INSPECTED
STREET ADDRESS 57 SummPrhP11 Ayannaf Cl- aigui11
ASSESSORS HAP , BLOCK AND PARCEL I
OWNER' s NAME John 'Healy
i
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr,
COMPANY NAME Joseph P. Macomber &''`Son, Inc.
COMPANY ADDRESS Box 66 Centerville MA. 02632-0066
5tr„t Town or City Atat• riP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa`1 system nt
>rL
his nddress rind that the information reported is true , accurate , and
omplete as of the time of '-inspection . The inspection was performed and any J
ecommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one ;
j_/,_//Systeri PASSED
h
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CHR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this Corm ,
System FAILED*
The inspection which I have con hcted has found that the system fails to
protect the Eitiblic health and the environment in accordance with Title
5 , 310 CHR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Y
Inspector Signature Date
Dtne
copy of this certification must be provided to the OWNER, the BUYER
where applicable ) and the 130ARD OF KEALTII.
• If the inspection FAILED , thv owner or operator shall upgrade the eyetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CHR 16 . 306 .
partd .doc
TOWN OF BARNSTABLE
LOCATION 5,7 6,vrWYUr ��' Ayc SEWAGE #
VII.LPt:r..• ASSESSOR'S MAP & LOTS.' - ,_
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: ( pe) � (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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 o leaching facility) Feet
Furnished by
Ave
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