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HomeMy WebLinkAbout0036 MAGNOLIA AVENUE - Health 35 MAGNOLIA LN., CENTERVILLE A UPC 12 as • 0 CO\1%10tr"-E A,I.TH OF MASSACHL;SETTS EXECUTIVE OFFICE OF E.N-VIR01 ME\TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE R'I\TER STREET. BOSTON NLA,0210S t617l 292.550k, TRUDY CORE Secretan ARGEO PALL CELLUCCI DAVID B STR:.'HS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 36 Magnolia Ave . Name of Owner Allan Dolby !q Hya ls7)Ort AddressofOwnerp _Rnx 109 rpntpryi l le Date of Inspection: ,%i ce-/ 0-0-Q Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved systerrl inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) CornpanyName: Wm. E . Robinson eptic Service MaBingAddress: PO Box 0 9, Centerville NA Telephone Number: 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 Inspector's Signature: 41rj 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 tfte system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS t revised 9/2/98 Page Iof11 n i• 3rried on Recycled Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'ropertyA r 36 Magnolia Ave . ,``Hvaa d is-port J er wn : frfan Dolbv - Date of Inspection: INSPECTION SUMMARY: Check B, C, o/ D: A. YSTEM PASSES: I have 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. O ENTS: B. SY TEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate ye , no, or not determined (Y, N, or ND). 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 ezfiltration, 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 pipets) 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 pipels). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed reviseY n " ,. 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Prop"Address36 Magnolia Ave . , Hyannisport Owner: Allan Do by Date of Inspection: 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. 1) 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. 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. 1' 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 i 9 g s equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 1 OTHER revise: 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) Prop"Address: 36 Magnolia Ave . , Hyannisport Owner,l lan D o lbv Date of Inspection: D. SYSTEM FAILS: You m indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N 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. LARGE SYSTEM FAILS: You must in licate either "Yes" or "No" to each of the following: Th following criteria apply to large systems in addition to the criteria above: Th 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 he Ith and safety and the environment because one or more of the following conditions exist: Yes N 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 r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of th Department for further information. revised r v ' / e 9/2, 98 PaRr4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Property Address: 36, Magnolia Ave . , Hyannisport Owner: Allan Dolby 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 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 receivmg normal flow 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 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 hot receive non-sanitary or industrial waste flow. Al _ The site was inspected for signs of breakout. j _ 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: _V _ 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)Ib The facility owner (and occupants,if differeru from owner) were provided with information on the proper"mintanaoco-0f Subsurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION _ 4operty Address: 36 Magnolia Ave . , Hyannisport Owner:A l lan D o lbv Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 96' g.p.d./bedro Number of bedrooms(design l:7 Number of bedrooms(actual): Total DESIGN flow-9-60 Number of current residents:, Garbage grinder lyes or no):-,)Lt°S Laundry(separate system) (yes or no):2� If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):ti to Water meter readings, if available (last two year's usage (gpd): 1999 161 , 000 gal. Sump Pump (yes or no):/L O 1998 152, 000 gal. Last date of occupancy:lG—�S-��j COMMERCIAL/INDUSTRIAL: Type o establishment: Design low: qpd ( Based on 15.203) Basis of design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last d to of occupancy: O R: (Describe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDSand 'ource of information: System pumped as partof inspection: (yes or no)LC. If yes, volume pumped: /tS-" gallons Reason for pumping: Ao L j�AJ �,� S - TYPE 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) 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). V rev-Lsen 9/2/9E Page 6(if ll ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address:36 Magnolia Ave . , Hyannisport ' Dwner: Allan Dolby Date of Inspection: BUIL ING SEWER: (Coca on site plan) Depth elow grade:_ Materi I of construction:_cast iron_40 PVC_ other(explain) Distan a from private water supply well or suction line Diam er Comm nts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grade:01-6 Material of construction: L-4Oncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth:��� 1 Distance from top of sludge..to bottom of outlet tee or baffle: Scum thickness: O . + Distance from top of scum to top of outlet tee or baffleZiTr _ Distance from bottom of scum to bottom of outlet tee How dimensions were determined: A.- 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of iquid level in relation to outlet inv t, structural rote rity, evidence of leakage, e0c.) �/ c:C.�� �} /� V 4 , � �. d T., Q� o 10k GREA E TRAP: (locate n site plan) Depth bel w grade:_ Material o construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensio Scum thic ness: Distance rom top of scum to top of outlet tee or baffle: Distance rom bottom of scum to bottom of outlet tee or baffle: Date of st pumping: Com ents: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) 'roperty Address:36 Magnolia Ave . , H.yannisport Owner: Allan D o lbv Date of Inspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth b low grade:_ Material of construction: _concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm •resent Alarm evel: Alarm in working order: Yes_ No Date f previous pumping: Co ents: (con lion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - ti I11 �LcJ 1� o`Z U D , 6 6 k PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms n working order (Yes or No) Comm ts: (note ondition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page sofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rap"Address: 36 Magnolia Ave . , Hyannisport Owner: Allan D o lb V Date of Inspection: 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;_ Altemative system: Name of Technology: Comments: (note condition f soil, signs o hydraulic_failure, level o ondin , dam soil, condition f vegeta on, etc.) o'Z C) S i o.v t 1 c, CESSPOOLS:_ (locate on site plan) Number and configuration: y✓� Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: S Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comme s: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) 1 Materi s of construction: Dimensions: Dept f solids: 'ell Comme ts: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9 2/7C Pagr9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ",ropenyAddress: 36 Magnolia Ave . , Hyannisport . Jwner: Allan D o lbv Date of Inspection:/—//,p CYT 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) ,C. z-w revised 9j 2/9R Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) roperty Address:36 Magnolia Ave . , Hyannisport Owner:Allan Dolby Date of nspeceon: 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 Estimated Depth to Groundwater P J F et 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 _zchecked 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) /3 0 � r.s+.l 7 L s J fY10 �L`- revise'. 9/2/96 Page tlof11 • -----'-. EB511Ei10E CEM -- � west wr.,,Rwortr,w •. ®' ® _ BCDMM F7 i ROOM CIA �� ® ® ® ® '��' - ... ' ®T BEDROOM BfOR�W R I STAR © ® O BATH r . ROOM i T HALL ' ® ® / , O 'r BEDROOM N w w aiaE>t no. I i r rxn i � i FIRST FLOOR PLAN $CCOfiD FLOOR PLATY r , ION I -------- -- ------------- COO Y`�oo�°y,53MaSSactaR� I! s 33DOREVE «AEFF ----- -----, _= a 6 "" ! Dv�j4Lk/ i w.t oG*'own ri loos Roos uo eoo►r�,ws ROOF CAM A / let 4E 36 (AKA # . ) 419 01-0 lww� 8" 'A Dalby, Alan J FAL iAM,CRAIG J '& LISA , 36 C-685-Q 5e Mmgno is Avenue r � 3o6\ LOC&T10 5EWo.(:�E PERMIT UO. VILLAGE IW5TQ R 1J� ADDRESS BUILDER 'S Q &M &,DDRESS DbiTE PERWT ISSUED D ATE COMPLI &MCE ISSUED : ���� �� 3�; �b b ��-�� y�- � � �� f 4 No. /7 � Fee 0 A THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migozal *pgtem Cottgtruction Permit Application for a Permit to Construct( )Repair(K )Upgrade( )Abandon( ) El Complete System O Individual Components Loc tion Address or Lot No. Owner's Name,Address and Tel.No. 3b Magnolia Ave , Hyannisport Allan Dalby Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septi Service P 0 box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4/5 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 S and. Nature of Repairs or Alterations(Answer when a plicable) New Title-5 septic system. Heavy dity tank, D-box and. 5pheavy duty chambers, with stone aii around.. 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 th' Bo rd of Heal Signed X, Date &Li? —9 3 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued f. No. /9 ' ®�O F Fee �D Q __V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZippYication for Mi 0!64 ttgtructiou erutit Application for a Permit to Cons ct( R pair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Loc rtion Address or Lot No. Owner's Name,Address and Tel.No. 3 Magnolia Ave , Hyannisport E Allan Dalby Assessor's MapTarcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson 3epti Service P 0 box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4/5 Lot Size sq.ft. Garbage Grinder( ) y. K 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 ap plicable) New Title-5 s e pt i e system*, Heavy cTtty tank, D-box and 7 heavy duty chambers, with stone a1I around . Date last inspected: Agreement: ` The undersigned agrees to ensure the'construction and maintenance of the afore described on-site sewage disposal system t in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi ckte.of Compliance has been issued by this Bo of Healt Signed�� i ' Date g—9 Application Approved by Date Application Disapproved for the following reasons { Permit No. Date Issued- . ------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS Dalby BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )' Abandoned( )by Wm. EgQbinson Septic Service at 36 Magno la Ave . ,H.yannisport has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Wm. E . Robinson S r. Designer The issuance p ° t s �jII not be construed as a guarantee that the sys a ill ction desni ed. '•� it Date e Inspector ------------------------------------- No. 9 O lr Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Dalby PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigpoar *pgtem Construction Permit Permission is hereby gr tod_to Cons ct( Repair{{--X)U glade( ))Abandon( ) System located at 3� magno la Awe . , Hyannisport 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: ( 1 Cf `f 9' Approved by TOWN OF BARNSTABLE LOCATION A AV SEWAGE # P of b VILLAGE 49� ESSOR'S MAP & LOT � INSTALLER'S AME&PHONE NO. b i N`S =ti 7 S -' 2 SEPTIC TANK CAPACITY 16->�� /4 1 l i LEACHING FACILITY: (type) 6 L. c (size)1. NO. OF BEDROOMS BUILDER OR OWNER DA /X�> PERMIT DATE: J I COMPLIANCE DATE:/ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leachi/g Facility Feet Private Water Supply Well and Leaching Facility (If any we/Us exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetl Zdsist within 300 feet of leaching facility) Feet Furnished by •� � ; / ; '.. i ay, ye' 3�o pi ��� ', I m @ * P fN .. 0va . t/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 PERN1IT (WITHOUT DESIGNED PLANS) I, W i ll iarn E . Robinson,S,rhereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 36 Magnolia Ave . , H,yannisport meets all of the following criteria: t The failed system is c ected to a residential dwelling only. There are no commercial or business uses associated with a dwelling. o The soil is classified s CLASS I and the percolation rate is less than or equal to 5 minutes per inch. m There are no wetlan within 100 feet of the proposed septic system _ There are no privat wells within 150 feet of the proposed septic system • There is no incr in flow and/or change in use proposed There are no v .aces 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 method when applicable J If the S.i. %will be located with 250 feet of any vegetated wetlands, the bottom of the proposed I leachin facility will not be located less than fourteen(1.1) feet above the maximum adjusted groun water table elevation, PI ••complete the following: A) Top of Ground Surface Elevation(using GIS information) g J B) G.W. Elevation +the MAX. High G.W. Adjustment .`—=-V DIFFERENCE BETWEEN A and B SIGNED : i �✓ -Q— DATE: [Sketch proposed plan of system on back]. q:health folder:cen Nk + ��'I/e'er .® � UR.e n/��' • . j i 'j2 pi. � � J 0 , A TOWN OF BARNSTABLE r,a LOCATION A SEWAGE # A �, VILLAGE .c SOR'S MAP & LOT s n f INSTALLER'S NAME&PHONE NO. !l d i SEPTIC TANK CAPACITY -b�� �"� �- LEACHING FACILITY: (type) (size)NO.OF BEDROOMS BUILDER OR OWNER PERMTT DATE: / -- 1- COMPLIANCE DATE: �'_.. Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leach Xg Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) X Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by _ i i i i