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HomeMy WebLinkAbout0016 TARAMAC ROAD - Health U 16 Taramac Road Centerville P A = 146 013 No. 4210 1/3 ORA Pendaflex 10% (1) i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS N Y d DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP ,� 1C - PARCEL, LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 16 Taramac Road,Centerville,MA 02632 Owner's Name:Douglas Capak&Dawn Roberts RECEIVED Owner's Address:16 Taramac Road,Centerville,MA 02632 MAY 14 2004 Date of Inspection: May 12,2004 Name of Inspector: REID C.ELLIS TOWN OF BARNSTABLE Company Name: ELLIS BROTHERS CONST.CO. HEALTH DEPT. Mailing Address: 23 ENTERPRISE ROAD, P.O.BOX 59,YARMOUTH PORT,MA 02675 Telephone Number: 508-362-6237 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 pursuan71ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: � � �/ Date: The system inspector shall submit 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. 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: Yanyll tt�� I have not foun= 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 a"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacemer t or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the or the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*oi the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration oi 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 wilt pass inspection if it is structure ly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availal le. ND explain: Observation of sewage backup or break out or hi static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven c istribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are r placed obstruction is removed distribution box is I veled or replaced ND explain: The system required pumping more than 4 times i 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 rq laced obstruction is remov 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: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 /� C. Further Evaluation is Required by the Board of ith: Conditions exist which require further evaluation the Board of Health in order to determine if the system is failing to protect public health,safety or the environme t. 1. System will pass unless Board of Health dete nes in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surfs a water Cesspool or privy is within 50 feet of a borde ing vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(ani I 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 absorpt on system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface orate supply. — The system has a septic tank and SAS and th SAS is within a Zone I 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 theSAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to deter nine distance "This system passes if the well water analysis, ormed 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 nitr gen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysi must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ackup 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 logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool , �'quid depth in cesspool is less than 6"below invert or available volume is less than %z day flow R tired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped _ portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ,,4ater supply. �y portion of a cesspool or privy is within a Zone 1 of a public well. A 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. [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 most be attached to this form.] N , o� A10,� (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 Systems: /sea To be considered a large system the system mere facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or`no"to each of following: (The following criteria apply to large systems in ad ition to the criteria above) yes no the system is within 400 feet of a surface inking water supply the system is within 200 feet of a tributar,to a surface drinking water supply the system is located in a nitrogen sensith a area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 1I of a public water supply well If you have answered"yes"to any question in Secti n E the system is considered a significant threat,or answered "yes"in Section D above the large system has fail .The owner or operator of any large system considered a significant threat under Section E or failed under S ion 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: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yet No Plumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? V s the system received normal flows in the previous two ?— .— Y p o week period . Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) V Was the facilityor dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,amcluding the SAS, located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the b es 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? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes nc 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 cc is unacceptable)[310 CMR 15.302(3)(b)] i 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 FLOW CONDITIONS RESIDENTIAL 2 Number of bedrooms(design): 3 - Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedro oms): �33 Number of current residents: p? j�(/��- Ga i l atp-'41 Does residence have a garbage grinder(yes or no).AZF Is laundry on a separate sewage system(ye or no):AZQ[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)):6�?Dcle�_ '91 va3 Sump pump(yes or no): AID Last date of occupancy: Cil 1A_ t, COMMERCIAL/INDUSTRIAL Al 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 n Water meter readings,if available: Last date of occupancy/use: OTHER(describe): 17�CC— GENERAL INFORMATION Pumping Records Source of information: �- Was system pumped as part o the ins ection(yes or no): /Vv If yes,volume pumped: gallons-How was uantity pumped determined? rN 9��� o?'✓ � Reason for pumping: ZE 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 copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): A pproxRnate age all co onents,date install (if known)and so ce of information: v-,5=�o Were sewage odors detected when arriving at the site(yes or no):�O 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 BUILDING SEWER(locate on site plan) 6U Depth below grade: c; Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction liner o 4-- Comments(on condition of jets,venting,e��e of leakage,etc - 12 r v r ! ��c 1�G fJn,N Ye.�✓ d N SEPTIC TANK:!&locate on site plan) G' Depth below grade:: I402f Ilih Material of construction:�ncrete_metal_fiberglass_polyethylene other(explain) A yAf tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) � Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3c 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: /I�v Comments(on pumping recommendairons,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related o outlet invert, v' a leakage,etc.)• 04 <zft GREASE TRAP:_(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 ffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 TIGHT or HOLDING TANK: (tank must be pum ,fait time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fi erglass 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: w(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: A10 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.): OV I 4. Vt& Otue_ ova te.f- PUMP CHAMBER: (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 f 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: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type Aching pits,number:— leaching chambers,number: Al f�yo7� leaching galleries,number: leaching trenches,number,length: . leaching fields,number,dimensions: /.✓'q ���o/ �y�,y�� � 30� /o w 2 overflow cesspool,number: innovative(alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, `OGL �t►/v S/ ,vs o /� �,y,.v Qs L f Ly,u— / //i.ol ✓l�L —ZWv y Gr /1r !✓�4s ♦z G,�ilw_ CESSPOOLS; A//141 g (cesspool must be pumped part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydra lic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic fai ure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts � Date of Inspection:May 12,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM N Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 00 feet.Locate where public water supply enters the building. o jf 10 • t J Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Taramac Road,Centerville,MA 02632 Owner:Douglas Capak&Dawn Roberts Date of Inspection:May 12,2004 SITE EXAM Slope ,L44'.e.L_ Surface water ,t,w Check cellar. Shallow wells Estimated depth to ground water /6 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) ecked with local Board of Health-explain: Checked with local excavators,installers- attach documentation) Accessed USGS database-explain: cC�-��� r You must describe how you established the high ground water elevation: 57 27 -- /�-d-.�• 3.S - �2h L f2 11 First Dawn & Doug Last Roberts Title Company or Current Occupant Address 16 Taramac Road City Centerville, ST MA ZIP 02632 Contact Information Work Phone Home Phone (508)420-5118 Fax Phone Alt Phone E-Mail Other AS-BUILT ON FILE YES X NO. I St pumped Date 10/09/2003 1000 gal septic tank Custom1 "owner as of 6/8/00 Douglas A. CARD SENT Capak according to book Custom3 DATE PUMPED 10/09/2003 DATE M: 146013 L:2 LAST PUMPED DATE NEW SYSTEM DATE INSPECTED Custom6 10/01/2003 10/05/2000 Bartolot send card 1 lqo No. civ"c� S r - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for 30iopood *potem Construction 3PCrrMit Application for a Permit to Construct( )Repair(,/Upgrade( )Abandon( ) El Complete System LJ'Individual Components Location Address or Lot No. Owner's ame,Address and Te).No. Assessor's Map/Parcel &)1- ceg l y�/_ vvlle Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder A/0 Other Type of Building_ &.S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow r� � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /P®O�' •SX/�J X Type of S.A.S. i Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this f Health. Signed Date l Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued �-- 7 7" > TOWN OF BARNSTABLE LOCATION /h �d�Q�'1?C �� SEWAGE # L�;.��/ VILLAGE C�� �l<�`f� ASSESSOR'S MAP & LOT/��_0/3 AL INSTALLER'S NAME&PHONE NO. _/ M)6rLOI SEPTIC TANK CAPACITY 14W7 s LEACHING FACILITY: (type) (size) /0 v(J ' NO.OF BEDROOMS 3 BUILDER O WNER c�x--�S PERMITDATE: `Z7-0� COMPLIANCE DATE: Q Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching,Facility �� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) i Feet Furnished by .15 C.r �taayac !L_� 6�cs .��> N _013 No. Fee c;av� sy �"._��.e,.-`" ...� � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Ztppliration for 0i5pogar *pgtetn Construction Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System L9'Irtdividual Components Location Address or Lot No. Owner's?Jame,Address and Tel.No. 16 Assessor's Map/Parcel r'-11"lle G-ems� , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Bort�1.� -7� 7/- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder()d Other Type of Building A e35 47 eee No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3.3Z) gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �li'i�OQ4' %Y/S�/�� Type of S.A.S. Description of Soil �©�✓3D X Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system' in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this f Health. / Signed ✓ Date Z AV Application Approved by Date 9`Z 7-q,&'''O Application Disapproved for the following reasons Permit No. 77 Date Issued �� 2 7— ____ THE COMMONWEALTH OF MASSACHUSETTS /416 " 13 BARNSTABLE, MASSACHUSETTS Certificate of Comptiance z THIS IS TO CERTIFY, that On-site SewOd Disposal System Constructed( )Repaired )Upgraded( ) Abandoned( )by D� G , at l h Q r�s��G y C l�G°j'�/i L has bbeen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Tc,*'L—» dated: Installer Designer The issuance of this permi yh/11 t e on trued as a guarantee that the syste P w .1 n/c�tjioJt 4-as d s-4ned/ l 2 6/ Ins ector i i't/ l/V� V Date p -------------------------------------- - �-D1 Fee No. 3 VC0— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwizpooar 6potetn on5truction Permit Permission is herebyranted to Construct Repair y U Upgrade Abandon g ( ) P ( )TAT" ) ( 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 t ' e t. Date: ` Z ^ ���� Approved by ,- t ��' TOWN OF BARNSTABLE LOCATION G t 9 k*P"" C A-e—OG01 SEWAGE # VILLAGE L' r✓l-yy1I VV\ k'y`-c-\ ASSESSOR'S MAP & LOT IN-STALLER'S NAME&PHONE NO. t 5 hG�2 �� l •j /��`d,7?•c�r'S e1�t SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 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 of leaching facility) Feet Furnished by provide a snnmv."•� , henrhmarks.Locate all wells within fp Ivr te {W N y• b 1 f�• 3Xr�4' , Q' y L12.ba to 0 n 10 TOWN OF BARNSTABLE ��A LOCATION / �arQ c r� SEWAGE # z41V✓ VILLAGE C��/r rill,Ile ASSESSOR'S MAP & LOT, INSTALLER'S NAME&PHONE NO. C011,04! SEPTIC TANK CAPACITY �pDD s T LEACHING FACILITY: (type)Iry • / (size) /9�3r '.X.2 ' ' NO. OF BEDROOMS PBUILDER O IWNER �d-4r1S PERMIT DATE: -Z 7-,0P COMPLIANCE DATE: �� 0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �¢ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) I/ Feet Furnished by CT � - I 621 1 Ire, NOTICE: This Form Is To Be'Used For the Repair Of Failed Se "tic Systems. Only. - CERTIFICATION OF SEITCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works PP p construction permit signed by me dated %/Z,612M concerning the property located at rd. meets all of the following criteria: /The failed system is connected t . syst . o a residential dwelling only. T'nere are no cotttme.ciai or business /roses associated with the dwelling. v i ae soil is classified as CLASS I and the percolation rate is less than or_goal :o : minutes per incu b"ne:e are no we•,lands wit hin 100 fee,of the proposed sepnc s stem :here are no private wels within 1-0 feet of the proposed septic system. 1 ae:a is no increase in flow and/or change in use proposed +' There are no variances.requested or ne--ded ,/The bottom of the proposed leaching facility will not be located less than five feet above the �ta:dmum adjusted groundwater table elevation. [Adjust the groundwater table.using the F dmptor method when applicable]. Xf the S.A.S.will be located with 250 feet of airy vege tated we.lands, the bottom or the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevati on, Please complete the following: A) TOP of Ground Surface Elevation(using GIS information) B) G.W.Elevation `� +the MAX High G.W. Adjustment. l = DIFFERENCE BETWEEN A and B SIGNED: DATE• (M=h proposed Plan ofSysam on back]. 4;haft I Wa.hat r Abel/ �4 r�✓IG� D � alb TQ��► mac rd