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Home My WebLink About0052 ALICIA ROAD - Health 152 AI;ICIA RD,HYANNIS w. �� J A 292.264-',. 1 ° ° I� t; 1 �jl I o Ili N ° ° 3 \ ` a r,� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name ' information is required for every Hyannis MA 02601 5/10/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab Inspector: 2 key,to move your 1. � J cursor-do not Ricky Wright (� use the return Name of Inspector key. B & B Excavation,lnc. Company Name I 14 Teaberry Lane Company Address Forestdale MA 02644 Citylrown State Zip Code 508-477-0653 S 14595 Telephone Number License Number B. Certification 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 pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ,. ® Passes ❑ Conditionally Passes ❑ ails _ N N ❑ Needs Further Evaluation by the Local Approving Authority _ *-a ' -� CD 5/10/12 Inspector's Signature Date C!� The system inspector shall submit a co of this inspection report to the A rovtn Aut orit Board Y P PY P P PP 9 Y (_ of Health or,DEP)within 30 days of completing this inspection. If the system fisa 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. ****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. f n t t5ins 11/10 Title 5 Offc al Insp cli Form:Subsurface Sewage Disposal System•Page 1 of 17 a , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 • 5/10/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C;D or E/always complete all of Section D A) System Passes: ® 1 have not found any 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 the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or 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 will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or 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 public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of.17 e `� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the.public health, safety and 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 SAS and the SAS is within a Zone 1 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 the SAS is less than 100 feet but 50 feet or more from a private water supply well**. iMethod used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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 must be attached to this form. 3. Other: i I D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup 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 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 %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply, ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins 11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis i MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection C. Checklist , Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two 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) ® ❑ Was the facility or,dwelling inspected for signs of sewage back up? ' ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank" inspected for the condition of the baffles 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? K• The size and location of the Soil Absorption System (SAS) on the site has i been determined based on: ® L❑ Existing information. For example,'a plan at the Board of Health. ` Q ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330. ✓ _'4. } jj e " t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 + , .+r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10112 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ' Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No . Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.6 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >20 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of Ieakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage_ Septic Tank(locate on site plan): ,. ti. Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: ' s years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No A, Dimensions: 1000 gal Sludge depth: no sludge t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 },4 i ' Commonwealth of Massachusetts, - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Alicia Road i Property Address . Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) a Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound - no sign of back-up. Grease Trap (locate on site plan): ' Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 4 - t 4k r Scum thickness t Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-111110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to be in good condition. No sign of solids carryover Pump Chamber(locate on site plan): Pumps in working order., ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required):. If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 -Official Inspection Form Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments M 52 Alicia Road I Property Address Ernest Culkins Owner Owner's Name information is Hyannis MA 02601 5/10/12 required for every H Y , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries' number: r z leaching trenches number, length: (2) 301 t s ❑ leaching fields s number, dimensions: ❑ 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, etc.): ' At time of inspection leaching appeared to be in good condition. No sign of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration , Depth —top of liquid to inlet invert ` Depth of solids layer ' 4V Depth of scum layer • Dimensions of cesspool ' r Materials of construction t Indication of groundwater inflow El ' • .;. ❑ No 't!Sins•11/10 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17Zj . . ~ r i 1. � +•�J r. '. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic 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 failure, level of ponding, condition of vegetation, etc.): 1 } t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of.Massachusetts w Title '5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch.Of Sewage Disposal:System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells.within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A2 ` .5 � QF-Ac d 0 , ,TtZENct{ 30f 15ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is required for every Hyannis MA 02601 5/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) i Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >15'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 52 Alicia Road Property Address Ernest Culkins Owner Owner's Name information is Hyannis MA 02601 5/10/12 required for every y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ®. System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file • , - r-mot y - y,t5ins,11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � � r 6 COMMONWEALTH OF MASSACHUS ETTS lag EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS' DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION `n\Q CAD, a 4 Property Address: 5 -eo r4,0 Owner's Name: _E�aU./E CULL/N S Owner's Address:22?7 S r 13f�,9oJ(„+/pjZ,��aj, 92G -h-/--0G wogg2; -InVA s 7733 g Date of Inspection:4 (24 ; p -2 Name of Inspector: (please print) VAN A. SPEAKNfAN Company Name: Mailing Address: Construction 15 Speak Way North Harwich, MA 02645 telephone Number: 1-508-432_5565 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 pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally PassesCD -'► T' Needs Further Evaluation by the Local Approving Authority `J' p'w Fails - �� fV Q Inspector's Signature: Date: o o m ry The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heath or DLL)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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Nines and Comments ****This report only describes conditions at the time of Inspection and under the conditions ofuse at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Tidc 5 Inspection Form 6/15/2000 page I t'a::c of OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I'roperty Address: 5? 4e— Owiicr: --- Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. SY.SICm Passes: �� _ _ Ilale not found any information which indicates that any of the failure criteria described in 310 CMR I i.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ( ummenls: 13. System Conditionally Passes: lih Onc or more system components as described in the"Conditional Pass"section need to be replaced or icpaircd.The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the_ for the following;statements. If"not determined"please explain. I'lrc septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound. exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the eNlltln!_tank is replaced with a complying;septic tank as approved by the Board of Health, `A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval ol•Board of Health): — broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND c.\plain: '['he system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed NO explain: 2 I'ier3 of'II OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z L/Gl S Owner C !JL Date of Inspection: C. Further Evaluation is Required by the Board of Health: A) Conditions exist which require further evaluation by the Board of Health in order to determine ifthe system is I.ailing•to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(6) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and 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 SAS and the 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. T'he system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance i "'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 ofammonia 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 must be attached to this form. 3. Other: r, i.. : i,.• .,,. .,., G ,..,, A/I cnnnn 3 Pace 4 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: pate of Inspection: p D. System Failure Criteria applicable to all systems: Ynu mast indicate"yes"or"no" to each of the following for all inspections: Yes No _�ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool .�scliarge 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 %day now ,__--Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.----. 4_�by portion of the SAS, cesspool or privy is below high ground water elevation, Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. W---Any portion of a cesspool or privy is within a Zone I of a public well. --4rny 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. IThis 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 must be attached to this form.) (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. i F. Large Systems: Al To be considered a Iarge system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) �-es no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— I WPA)or a mapped Zone 11 of a public water supply well II'you have answered "yes"to any question in Section E the system is considered a significant threat,or answered ..yes** in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 5..304.The system owner should contact the appropriate regional office of the Department. Pa,e 3 of*I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2 L CI Y, Owner: C VL Date of Inspection: p ('heck il'the following have been done. You must indicate" es"or"no"as to each of the followin Yes No Pumping information was provided by the owner, occupant,or Board of Health .✓ ere any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period ve 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) . Was the facility or dwelling inspected for signs of sewage back up" .� Was the site inspected for signs of break out -� Were all system components,excluding the SAS, located on site l•__ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition 01'tlie baffles 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 11laI Mena lice of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on:' Yes no .� 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 is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: hIS Owner: U Datc of Inspection: o FLOW CONDITIONS RESIDENTIAL Numbcr ol•bedrooms(design): 3 Number of bedrooms(actual):__Z. DI:SIC,N flow based on 310 CM 15.203 (for example: I I O.gpd x #of bedrooms): 3 30 Number of current residents: Dues residence have a garbage grinder(yes or no): AJo Is laundry on a separate sewage system(yes or no):Lti [if yes separate inspection required) Laundry system inspected(yes or no):— Seasonal use: (yes or no): GVa water meter readings, if available(last 2 years usage(gpd)): u 3�0�� l L� ' j 3 �S2 I 0� �LUV tiump pump(yes or no): OUG 3r Lust date of occupancy: I , COMMERCIAL/INDUSTRIAL I%pc of establishment: Design flaw(based on 310 CM 15.203): _gpd Basis ul'design Flow(seats/persons/sgft,etc.): (ircase trap present (yes or no): ..__ Industrial waste holding tank present(yes or no):_ Nun-sanitary waste discharged to the Title 5 system(yes or no): — Water meter readings, if available: Last date ofoccupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records I /. Source of*in formal ion: tCVojEff?-- W'as System pumped as pan of the inspection(yes or no): ;V a II'ycs, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping:. ---- TYPF' F SYSTEM __. Scptic 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): Approximate age ol'all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): RJle-Z' r,i.. : i .• ...•�:,, r:,,.•.. 4/1 c nnnn 6 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 11'ropertl' Address: 2 G C/ , Owner: C UL*-Itkzi Date of Inspection: �i 7 IWILDINC SEWER(locate on site plan) Depth beh;w grade: may." f Materials of construction: �t iron _40 PVC_other(explain): _ Distance from private water supply well or suction line: Contntents(on condition of joints, venting,evidence of leakage,etc.): _ ti1-;I TIC TANK: —Trocatcon site plan) Depth below grade: 12 w Material of construction: _ c�ete—metal—fiberglass_polyethylene other(explain)--- _ II'tank is metal list age:---- Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of ceilificate) Dimensions: /QoO , Sludge depth: .--.---• � ---_ } Distance from top of sludge to bottom of outlet tee or baffle: 3/ Scum thickness: — _ — Distance from top of scum to top of outlet tee or baffle: 8 �� Distance Irom bottom of scum to bottom of outlet tee or baffle: I low were dimensions determined: 1624Gbq Is 02 elo � Comntenls(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE.TRAP:41ocate on site plan) Depth below grade: _ Material of construction:_concrete_metal —fiberglass_polyethylene__other (explain): Dimensions: Scum thickness: - --- Distance li-ont top ot'scum to top of outlet tee or baffle: _ Distance from bottom ofscum to bottom of outlet tee or baffle: Date of last pumping: - _-- (.'onunenis(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 L C Yid Owner: ;f Dale of Inspection: O "FIGHT or HOLDING TANK:AJ*(tank must be pumped at time of inspection)(locate on site plan) Dcp(h below grade: Material ol'construction: _concrete.--meta l fiberglass__polyethylene other(explain): Dimensions: _ ______ Capacily: ..__. _..._. _. __gallons Desiun Flaw: _ „ _ _galIons/day :alarm prescnl (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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OV Comments(note if box is level and distribution to'outlets equal,any evidence of solids carryover,any evidence of leaka;gc into or out of box, etc.): 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 of pumps and appurtenances,etc.): f r 8 I'a�e 9 01'11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: L �S bate of Inspection: SOIL ABSORPTION SYSTEM (SAS): �ocate on site plan,excavation not required) II'SAS not located explain why: leaching pits, number:_ leaching chambers,number: leaching galleries,number aching trenches,number, length: i leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technolo �'n mments(note condition of soil,signs of hydraulic failure,gevel of ponding,damp soil,condition of vegetation, etc.): ('I'SSPOOLS: cesspool must be Pumped as part of inspection)(locate on site plan) Number and configuration: Depth.••top of liquid to Inlet invert: Depth ol'solids layer, ` Depth of scum layer: Dimensions orcesspool: Materials of construction: Indiculion of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic fallure, level of ponding,condition of vegetation,etc.): PR I V Y: V.41(locate on site plan) M;uerials ofconstruction: Dimensions:_ I)eplh of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 4ii cnnnn 9 I'a}v I U of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i 11ruperty Addreu; Aucl,4 • S (hvncr, S Dote of tnspeetlont v W•TCtt OF SEWAGE DISPOSAL SYSTEM Providr u sketch orthe sewage disposal system including tics to at lout two permanent reference landmarks or twnchmsrkL Lochs all wills within 100 feet;Locate where public water supply enter:the building. o ------------ 2 Zo ' 21 ' Z 31�,3 ' Y3 . 3 ' 0 o r; �.,c i,,...�•�r�c .err4AW 10 I'a,c I I o1• ,OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: e- u14 W-il at •r (honer: C e.)L ft✓/mil Mile of Inspection: '7�7 .SIT : h.XAM SIopc Surface water Check cellar . Shallow wells Istimatcd depth to ground water 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) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 1 Town of Barnstable pp 1HE 1p� P� o Regulatory Services BARNSTABLE Thomas F. Geiler,Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. • t . .�� .,� � `� �,� .,, .. t ' � „ i � � � � ! TOWN OF BBARNSTABLE LOCATION So �� 1� " SEWAGE # .VILLAGE ASSESSOR'S MAP& LOT , INSTALLER'S NAME& HONE NO. SEPTIC TANK CAPACITY LEACHING FACIL=— (type) _�d�s'�-�-� (size) 'NO.OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: -�� 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 I. IN � W j TOWN OF BARNSTABLE G/ LOCATION S^� /,r.G�� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 4 INSTALLER'S NAME HONE N0. & ' SEPTIC TANK CAPACITY "�®zy LEACHING FACILITY: (type) (size) �® NO. OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: -��D COMPLIANCE DATE: .S~ -.^;L l �(9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by No. �— a 9la iy Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for 30i.5po al *pgtem Con.5truction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) []Complete System O Individual Components �ocation Address or Lot No. Owner's Name,Address and Tel.No. ov- /36 sS� A, 1Cv'� 4� 1- ...�Ls SvLQ�•,� $�►^�-�At� Assessor's Map/�arcel Install�ey'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( N� 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 Nature of Repairs or Alterations(Answer when applicable) O 1r.e✓ P�aC�� .ca '�� >xa��-. Go fa.��c � ' wtc�� c 2 c�eQp 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 Board of Health. Signed Date .--S' 0- S Application Approved by Date b4,_., �%9 Application Disapproved for the ollowrng reasons Permit No. 9°/- :L Date Issued r J No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Tipaplication for Migogaf A)pgtem Congtructtonr Permit Application for a Permit to Construct( )Repair( /)Upgrade( )Abandon( ) O Complete System ❑Individual Components �ocation Address or Lot No. Owner's Name,Address and Tel.No. ov- /36 SSA A I 2. S'►-j3P-Sv� Assessor's Lap arcel� Installlej's Name,,Address,and Tel.No. Designer's Name,Address and Tel.No. `31 edsr_ Type of Building: - Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( Np Other Type of Building No.of Persons Showers( ) Cafeteria( ' ) Other Fixtures r 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 Nature of Repairs or Alterations(Answer when applicable) ac�A_ 0 r.e� P4C�_, cr -tie Ac.�. 60 �e.,4 4 wrcl� �c 2 cieQp • Date last inspected: Agreement*". ` The undersigned agrees to en a the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o Title 5 of the Environmental Code and not to place the s� stem in operation'until a Certifi- Cate of Compliance hasbeen issued this Board'of Health. Signed �..._--- --��a. Date S -c0=y f Application Approved by ds Date�g�r_9j 9 a Application Disapproved for the ollowing reasons ._ a Permit No. ��'- �� Date Issued t ------ --- I --_— - + -- CO;MON;EALTH OF MASSACHUSETTS THE BARNSTABLE, MASSACHUSETTS �-� -'--Certificate of Compliance THIS IS TO CERTIFY, thatt th"e-On_site Sewage-Dispo sal System Constructed ( )Repaired ( W<U�Pgraded ( ) Abandoned( )by at SL Pl��s �`�•._ \�y� " -._ "', has been constructed in accordance with the provisions of Title 5 and the for Disposal'Syst m Construction Permit N_o-_ �-.�94 . dated Installer _ -' De5gner The issuance of this permit shall no bge construed as a guarantee that th system i unction as designed Date S' - �/ Inspector No. — Fee Sa THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wigpogar *pgtem Construction Permit Permission is hereby ranted to Construct( )Repair( �Up rade( )Abandon( ) System located at ?Z Ph�-ICk� �-�- )TZ4 " 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 thimyears of the date of•this`permit. Date: �' �.0 - `� 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 PERT IIT (WITHOUT DESIGNED PLANS) h or` �er �hS hereby,certify that the application for disposal works construction permit signed by me dated , ,5— zO concerning the property located at �� .( � meets all of the following criteria: +/The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. I • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. •v--There are no wetlands within 100 feet of the proposed septic system • ,l ere are no private wells within 150 feerof the proposed septic system •&/There is no increase in flow and/or change in use proposed •here are no variances requested or needed. •, The bottom of the proposed leaching facility will not be located less than five feet above the V ma..imum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] - the 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) B) G.W. Elevation 41—+the MAX. High G.W. Adjustment. _ D9 ERENCE BETWEEN A and B SIGNED : P '!��-��v DATE: 3'-W -qq (Sketch proposed plan of system on back].. q:health folder.cent N r a r - � M G3 I 1 f r7 TOWN OF BARNSTABLE LOCATION SEWAGE # a VILLAGE ASSESSOR'S MAP & LOT 6 "1 INSTALLER'S NAME& HONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _;Zf (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: -�a� 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 Feet within 300 feet of leaching facility) Furnished by "�