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Home My WebLink About0014 WESTMINSTER ROAD - Health 14 WESTMINSTER RD., CENTERVILLE A= 168 063 AREcrccEo� =J gym UPC 12543 No.63LO HASTINGS,IUN No.OV/C Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes applitation for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No. � I y W s s'�'vhv.�" Owner's Name,Addres and Tel.No. q/ — 3.5,$-//74 Assessor's Map/Parcel I�pp NP3 ILI r�� p Installer's Name,Add s,and Tel.No.5 $77 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size ��S r A sq.ft. Garbage Grinder( ) Other Type of Building g&Je,`'`�`a1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil A- A Nature of Repairs or Alterations(Answer when applicable) Li i V-m4L C, 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 Certificate of Compliance has been issued is Board of Health. ig ed p Date Application Approved by Date Application Disapproved by r Date for the following reasons Permit No. Date Issuedtall kg No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Misposal obpstem (Construction Permit- Application for a Permit to Construct( ). Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. l 4 W y S'r "K�- � Owner's Name,Address,and Tel.No. Q/(- 3 55-//7(, Assessor's Map/Parcel �� 'W� .h �'► L S1 ,v��Q.isd�� Installer's Name,Address,and el.No.'5v g-q 17 8 877 Designer's Name,Address,and Tel.No. _ C �Jtdt2 IQs a Type of Building: , Dwelling No.of Bedrooms Lot Size .�� / ` sq.ft. Garbage Grinder( ) y�i Other Type of Building Q S, N,v�t 0.1 No.of Persons Showers( ) Cafeteria( ) i' Other Fixtures y, Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title s�. Size of Septic Tank Type of S.A.S. ,Description of Soil 1 Nature of Repairs or Alterations(Answer when applicable) 1._j vlQ_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal sykem in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issuedrbth's•Board of Health. «i tg ed Date d--q 2- Application Approved by Date Application Disapproved y Date for the following reasons • F Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance --- THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(am ) Upgraded( ) Abandoned( ),bye at Tom`,*f�`f�r� o Q-�� has been constructed in accordance p� with the provisions of Title 5 and the for Disposal System Construction Permit No ated Installer Cop, ,; E�'i- � r Designer. #bedrooms Approved design flow gpd The issuance of this permit shall no be con 7ted as a guarantee that the sy tem-wl• ,io• esign d. Date / C/ , Inspec or '---- No. - Fe _--1k" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(V/) Upgrade( ) Abandon( ) System located at i-t- C. t��1-o i .i and as described in the above Application for Disposal System.Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction st completed',within three years of the date of this permit. Date / _ / Approved by / , i if No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Mi5po5ar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(.Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. a Owner's Name,Address and Tel.No. 1 )� 0 633°� ��o q�l Assessor's Map/Pazcel Installer's Name,Addre,3501MoStreet Vf a Designer's Name,Address and Tel.No. W. Yarmouth, MA 02673 l Type of Building: Dwelling No.of Bedrooms 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 1407) E451f,lt Type of S.A.S. 5_00 0,44 hr�rIellf Description of Soil Mez ;1P Nature of Repairs or Alterations(Answer when applicable) Lh Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thfM of Health. Signed Date /Q-4(- Application Approved by Date_lei -y r Application Disapproved for Ne following reasons Permit No. 99•- Date Issued No. -S�� rr Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ` 0(pprication for Digpo.5af 6petem Con.5truction Permit Application for a Permit to Construct( )Repair(.ojtpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./ ��{ '/+S•��r Owner's Name,Address and Tel.No. Assessor's Map/Parcelefel_ / Installer's Name,AddreA A 91. U CANC (p Designer's Name,Address and Tel.No. 'f S o� 350 Main Street W. Yarmouth, MA 02673 N / Type of Building: Dwelling No.of Bedrooms 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 /GY"16 E45 rtC, Type of S.A.S. SOO AAA, i l'y"It'lld Description of Soil mex. tlai cr Nature of Repairs or Alterations(Answer when applicable) -_n,5ka1j i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thtAor of Health. Signed Date !d-q-9 9 Application Approved by Date Application Disapproved for Re following reasons t Permit No. 9,9 s ri Date Issued ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( d)-YJpgraded( ) Abandoned( )by e,-'4A*d at !,j f ` i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Q5P- 6 5r 3 dated Installer Designer The issuance of this permit sh 1 no b c nstrued as a guarantee that the will fu .cti p des Date Ins ector V1 K, -----C------------------------0-------�—^�-- No. r � 6 J Fee y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigpool &pgtem Construction Permit Permission is hereby granted to Co truct( )Repair( &oCpgrade( )Aband ( ) 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: �L5 N �,� Approved by_ 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, �� hereby certify that the application for disposal works construction permit signed by me dated ! — Y- T_ concerning the property located at �°E�e�7�ld'J</j ��' meets all of the following criteria: dwelling The failed system is connected to a residential . g only. There are no commercial or business uses associated with the dwelling. Q/ • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic stem P �' ✓There are no private wells within 150 feet of the proposed septic system a/ • ere is no increase in flow and/or change in use proposed There are no variances requested or needed. (/• The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor Zth thod when applicable] e S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) Llc,t B) G.W. Elevationd 7•3 +the MAX.High G.W. Adjustment DIFFERENCE BETWEEN A and B SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cert ffo TOWN OF BARNSTABLE LOCATION��/Yl/i't �7 �� SEWAGE # 6 J r 3 VILLAGEJ�Jd,'ZeeV//6e__ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. .�/1l-G� -77 5-, a Rao SEPTIC TANK CAPACITY i LEACHING FACILITY: (tyKe �� (size) 5 '� i NO. OF BEDROOMS BUILDER OR70�� 3�, PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 i within 300 feet of leaching facility) Feet i Furnished by --- --- ------ i i i i I O I i 10 . O TOWN OF BARNSTABLE r SEWAGE # V 6 :53 1"JE� /fASSESSOR'S MAP & LOT 3 INSTALLER'S NAME&PHONE NO. ( .Qi'1[,ca -77 5—, elr?® SEPTIC TANK CAPACITY LEACHING FACILITY: (ty�e &MC?, (size)o?�X �•� D2 NO.OF BEDROOMS BUILDER OR OWN PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 or 46ujle- / 1 rt i Y3 o � e 2 Commonwealth of Massachusetts 10. Executive Office of Environmental Affairs NOV Department of • to�tl�e►u�.'�o�tE Environmental Protecti WIIIIarn F.weld r 603 Trudy Cox• DwM L Struhs f'e ) IJfURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION /D T Property Address: / Address of Owner: Date of Inspection: Jr d " 11- V5 (if different) Nameoflnspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT 7 7��. I certify that I have personally inspected the sewage dispels s s e t this address and that the information reported below is true,aotaxate 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: °F _✓ Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails _ 00, L Inspector's Signature: W i Date: O—3/—�1 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTE PASSES: 71 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] .SYSTEM CONDITIONALL ASSES: One or more system mponents need to be replaced or repaired. The system, upon completion of the replacement or nepvtt, passes inspection. °Indicate yes, no, or not deter ined (Y, N, or NO). Describe basis of determination in all instances. If"not determined", explain**noo _ r urall unsound shows subs tantial infiltration or exfiltration, or tank failure is The Sept' tank rs metal, cracked, st uet y , immi I t. The system will pass in if the existing septic tank is replaced with a conforming septic tank as approv by the Board of Health. (revised 9/ls/95) 1 One Winter Street a Boston,Massachusetts 02106 • FAX(617)SWID49 • Telephone(617)292'00 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: l gal V. ill lnsyee Rj�2 C e,7-rer at Owner. Ov. Date of Inspection: 3 95 B�SYSTEM CONDITIONALLY PASSEE)n Sewage backup or high static water level observed in the distribution box is due to broken or obstr used pipe(s) or due to a ed or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): ken pipes)are replaced struction is removed tribution box is levelled or replaced The system requireore than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with he Board of Health): ken pipe(s) are replaced struction is removed C) FURTHER EVALUATION IS REQUI D BY THE BOARD OF HEALTH: Conditions exist which require f her evaluation by the Board of Health in order to determine if the system is failing to protect the 'public health, safety and the envi onment. 1) SYSTEM WILL PASS UNLESS BO RD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PU LIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is wit n 50 feet of a surface water Cesspool or privy is wit in 50 feet of a bordering vegetated wetland..or a salt marsh. 2) SYSTEM WILL FAIL UNLESS T BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONI IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and so absorption system and is within 100 feet to a surface water supply or tributary' to a surface water supply. _ The systen, has a septic tank and soil a sorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil a orption system and is within 50 feet of a private water supply well. _ The systen, l.as a septic tank and soil ab orption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysi for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• DI SYSTEM FAILS: 1 have determined that the system violates or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility r system component due to an overloaded or dogged SAS or cesspool. Discharge or ponding of a ent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. (revised 8/15/95) 2 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �/ 1./. Rig Ce-,z-re,'d,'j'I� Owner: H. 6✓Ls ?" Date of Inspection: S DI SYSTEM FAI.S(continued): 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. El LARGE• YSTEM FAILS: he following criteriaiply to large systems in addition to the criteria above: he design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety nd the environment because one or more of the following conditions exist: 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 owner operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirementsA 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11151911 3 5 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �, ��s� • Owner. Date of Inspection: Check if the following have been done: 4/Pumping information was requested of the owner, occupant, and Board of Health. L14one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rases 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 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 4/he site was inspected for signs of breakout. _LIAII system components, excluding the Soil Absorption System, have been located on the site. _fhe 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. 324he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. 4;Tehcilit� owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- e Disposal System. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: mInsr-el* Rw Ce.17ret 1!l 11C-d Owner. H `r/.e, s T/ Date of Inspection: 93 FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: Number of current residents:, Garbage grinder(yes or no):A� Laundry connected to system (yes or no):� Seasonal use (yes or no): /L/ Water meter readings, if available: Last date of occupancy: /0-• a`—�f 7 COMM INDUSTRIAL- Type of establi ment: Design flow: Ilons/day Grease trap prese t: (yes or no)_, Industrial Waste H Iding Tank present: (yes or no)_ Non-sanitary waste ischarged to the Title 5 system: (yes or no)_ Water meter readi s, if available: Last date of occu ncy: OTHER: (Descri ) Last date of occ-,paAnn�y: � GENERAL INFORMATION PUMPING RECORDS and source of infor ation: / S 46 G System pumped as part of inspection: (yes or no) ' If yes, volume pumped. gallons Reason for pumping: TYPE 90F4STEM 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) t (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /y Owner: Date of Inspection: SEPTIC TANK: , (locate on site plan) r ' Depth below grade: Material of construction: Yoncrete _metal _FRP—other(explain) Dimensions: Sludge depth:= D Distance from top of sludge to bottom of outlet tee or baffle:♦ Scum thickness: 2-!6 ► ► Distance from top of scum to top of outlet tee or baffle:a" Distance from bottom of scum to bottom of outlet tee or baffle: l a Comments: (recommendation for pumping, condition of inlet and Qutlet tees or baffles depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) _ ar . GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: concrete_metal _FRP—other(explain) Dimensions: Scum thickness Distance from top of scum t top of outlet tee or baffle: Distance from bottom nt 5rt to bottom of 01.16et tee or baffie: Comments: (recommendation for pum mg, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of lea ge, etc., W� .. I (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continue Property Address: /y Owner: �`- 4/,es Date of Inspection: TIGHT OR HOL G TANK:_ (locate on site plan) Depth below grade: Material of construction _concrete_metal _FRP_other(explain) Dimensions: Capacity: as ons Design flow: a Ilons/day Alarm level: Comments: (condition of inlet tee, co dition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: (3 Comments: (note if level and distributiun is equal, evidence of solids carr?,o•:cr, evidence of leakage into or out of box, etc.) /L B PUMP CHAMBER:_ (locate on site plan) 7 Pumps in working order:(yes or no) Comments: (note condition of pump chamber, con ition of pumps and appurtenances, etc.) I (revised B/15/95) 7 IL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: y Owner: Date of Inspection: /— SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) ' If not determined to be present, explain: Type: J leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, I vel of ponding, condition of vegetation,etc.) CESSPOOLS: (locate on si pla Number and configurat n: Depth top of liquid to in t invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow(cesspool ust be pumped as part of inspection) Comments: (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Of PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of so', signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (rev ised"8/15/95) 8 6 (SG/ST/Y poet"j). i :uopewlxadde jo uoiieuluuaap Jo p04Ww pa)=uawAokpunoa of 4vioa 83LVMaNnovo Ol Hum l ` f ,3 J e001 ul4uM sllam Ile ORMI s4jewLpuaq jo s4lewpuel swuai" juauawad oiw)seal it of salt apnpul :WUSAS 1VSOdSIa 37VM35 JO H:)13XS UBUMO -imp"4M94 Qmuf w) NOLLVWIIOINI WUSAS 3 18Vd WVOJ NOIDUSNl W31SAS iVSOdSIa 37VM3S 3avianso 1S TOWN OF BARNSTABLE LOCATION CC-rJfiC2tJ1 IE SEWAGE# 'VILMI GE� I�6S 1 M I NS' ASSESSOR'S MAP &LOT INSTALLER'S NAME&PH ra ONE NO.. W E Ro�trtlSOY•� SeB-cc "7 7S- 77(- SEPTIC TANK CAPACITY i D oC� LEACHING FACILITY: (type) (size) NO.OF BEDROOMSC BUILDER OR OWNER PERMTTDATE: 6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 t J � i � . y � _ - - �