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Home My WebLink About0068 CARLA ROAD - Health 68 Carla Road Hyannis A = 248'='1'63 f o 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,.. 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 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 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 B I e dan Ln. Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this add@Tss and thafIbe information reported below is true, accurate and complete as of the time of the iq ection. Thy-'inspection was performed based on my training and experience in the proper function and maintenance,!g on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 0 Title 5(310 CMR 15.000). The system: CIO �—a ® Passes ❑ Conditionally Passes ❑ Fails ' ❑ Needs Further Evaluation by the Local Approving Authority 9/10/2013 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. b5113 t5ins•3/13 Title 5 Official Insp ion,orm:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 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: ® I 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: The dwelling located at 68 Carla Rd Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 leach trenches 32'x4'x2'. The system was found to be in roper working condition at the time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 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". Method 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: 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 Y2 day flow t5ins•3/13 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 ,M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Cityrrown 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. t5ins•3/13 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 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Citylrown 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 an of the m n❑ ® y e 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? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 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-3113 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 ,M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 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 i ❑ 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): t5ins•3'13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system repaired 6-12-1996 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet. Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons 6., Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was cleaned after inspection for routine maintenance and should be done regularly every 2 years to prolong the lifespan of the system. Water level was even with outlet invert, tank was not leaking and was structurally sound. Inlet and outlet tees were intact. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title f 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Cityfrown 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•113 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 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. CityrFown 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 32x4x2 ❑ leaching fields number, dimensions: overflow cesspool number:p ❑ 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.): soil and stone surrounding leach trenches was probed and was found to be dry with no sign of past saturation. 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 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Cityfrown 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Citylrown 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 o O 1 2 pr-r= 31 (3-1 =3Z 13'Z q3 t5ins•3/13 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 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 68 Carla Rd Property Address Debra Martin Owner Owner's Name information is required for every Hyannis Ma 02601 9/10/2013 page. Cityrrown 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. P Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Mizpaal bpftem Cootructton Permit Application is hereby made for a Permit to Construct( )or Repair( Ll an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. to a CO3_ eA,:,o i &,WA,ms � �,�� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 7K_130 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) =L&�M" k'� MS edscm 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 a d no place the system in operation until a Certifi- cate of Compliance has been issu alai of Sig eff d Date u`/I �i� Application Approved by Application Disapproved for the-following reasons Permit No. �' Date Issued ,�- � loe No. vs' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS t Application for Mtgpogar *pgtem Cootrurtton Verna Application is hereby made for a Permit to Construct( )or Repair( 4non-site Sewage Disposal System at: i Location Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel:No. Type of Building: Dwelling No.of Bedrooms �� Garbage Grinder( ) '( Other Type of Building No.of Persons Showers( ) Cafeteria( ) iE Other Fixtures F Design Flow gallons per day. Calculated daily flow 3730 gallons. Plan Date Number of sheets Revision Date Title Description of Soil i iII E i €. Nature of Repairs or Alterations(Answer when applicable) =y— r4`k 0--0. `-ru-0 So x'.(,ems "t V`e'wc(e 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 a d not,t place the system in operation until a Certifi- cate of Compliance has been issue of fit Signed Date `j Application Approved by - Application Disapproved for the following reasons Permit No. � Date Issued �<"'" ( THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certif tcate of Com phance THIS IS TO CE ,th thq_0n=siteSwage Disposal System installed( )or repaired/replaced on cD by AS for W'%Q, O ex SS\ A'N1A e as a" hasJaern construed in apc9rda e with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth D .;1c3'w: 6• r° i�. No. �1- Fee i .THE COMMONWEALTH OF MASSACHUSETTS 4 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mtgogal *pgtem Conmructton Vermtt Permission is hereby granted to to construct( )repair(\_*'an On-site Sewage System located at �-1 totx,o-A_S 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. All constructiou must becompleted w'thin two years of the date below. Date: /� iy' Approved by i pp CERTIFICATION OF SKETCH AND APPUCA rA WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) -_ - --�- t t_k- ��" �..� { �t t g �, �3.+uaf N F y �1 `�'• °}�&'�t`�`�':�J,jhyj, 't'7 3 g a {7l";V I r�JCc1 ✓7� hereby certify that the a on for Al arttic� construction permit signed by me dated property located at i following criteria: ¢ z. ,a^b air.�er � vo- �• " r�3'tdr� .+;r� �42- 1`' 'i�4 • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septln#stent`X' • The observed groundwater table is 14 feet or greater below the bottom bfil }teachlitg idlilj► • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. �� ?fir` �.+ .••q& I t I � �, ,� Arm- 3 t 0614 f r ��•��•Mt�.ltiy��ki i+}r� l 4'T �T ;�`}a'T S��' M�:{Gh,��V�ytt;. SIGNED: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF B ABLE [Attach a sketch plan of the proposed system. Also if the licensed Installer p a%IW a this plan should be submitted]. r 3M�3�,r�•t.Y 9 t Sx 't�$X'rT'j✓` •,�� .e 4 t��..: �I r�•k r u !r ''°� �".j's Xtis, 04 ..• � '�'.y�a,�,rt�� +>r 't c s it r� �' y`3'' ra� �� '`� t5t'9 4 I t _ f f c DATE: .5/7/96 l� PROPERTY ADDRESS: 68 Carla Road Hyannis ,Mass . "at 02601 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 2-6 1 x8•1 Block cesspools . IES$QRSMApN 1 a PARCMNk . Based on my Inft;-ectlon, I certify the following conditions: 1 . This is not a title five septic system 2. this is a sewage system 3 . The sewage system is in failure . 4. Both cesspools are filled to capacity. Scum layer on main cesspool is above the invert of inlet pipe . Water is above the out let invert of main cesspool. 5 . Must be upgraded to a title five septic system. SIGNATURE: Name : J . P .Macomber Jr.. COm an J P . Macomber & Son Inc . Address:_� _��,------- -- -_ _ CentervilLe ,MLq s.__02632 P h o n e:---50.8--7-7-5-3338-----_-- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY In nM .19SEPH P. MACORRBER & SON, INC. Tanks-Cesspools-Leachfields . Pumped Q Installed Town Sewer Connections P.O. Box 66 ' Centerville, MA 02632-0066 775-3338 775-6412 f U Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WUllam F.Weld Trudy Coxe Gowmor Swatary Argoo Paul Celluccl David S.Struhs LL Gowmor Cortvdsskx*r e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 68 Carla Road Hyannis ,Mass . Address of Owner. Date of Inspection: 5/2/9 6 (If different) Name of Inspector.. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc.. Box 66 Centerville ,Mass . 02632 508-775-3338 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 SIgnatur : o r ,,QLldd ' �414 4 Date: 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 gygtem owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSESd &0 I 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 CONDITIONALLY PASSES: A do o thereplacement One or more system components need to be replaced or repaired. The system,upon completion n f or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain.why not) Al&& The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,-or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02108 Is FAX(617)556-1049 • Telephone(617)292.5500 0 Primed on Recycled Paper SUBSURFACE SEWAUE LIZZWV�AL 0iairm a-40"A'., PART A CERTIFICATION (oontinuod) Property Address: 68 Carla Road Hyannis ,Mass . 02601 owner. Winfield D. Smith Data of Inspection: 5/2/96 III SYSTEM CONDITIONALLY PASSES (continued) iVO,'V& Sewage backup or breakout or huh static water level observed in the distribution box is due to broken or obstructed pipe(s) 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 pipe(s). The system will pass' inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: IbIZ>_ 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: AM 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. 410 The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. L� The system has a septic tank and soil absorption system and 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 is equal to or Isla than 5 ppm. 9) OTHER The system consists of two 61x8t block sgnonlG _ Main pool acts as a Sep I t jn Sn1jr1q Jn allows the effluent to pass to the second cesspool. ( Overflow Tee is broken and is on the bottom of the main cesspool (revised 11/03/95) 2 SUB9URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontlnuod) Prop•crty Addross: 68 Carla Road Hyannis ,Mass . 02601 owuar. Winfield D. Smith D a to of Inspootlo a: 5/2/9 6 if D) SYSTEM FAIM I havy determinod that the rystam violnt.os one or more of the following failure criteria as deQnsd in 310 CbIR 16.509. The basis for this determination is identl.Cwd below. The Board of Health should be contaetod W determine what will be aeoeasary to correct the failure. - Backup of sewap into facility or sy?tRm component due to an overloadod or clogged SAS or cosspool. Discharge or poading of eflluent to the surface of the trouad or surface waters due to an overloadod or clogged SAS or cesspool. Static liquid level in the'diitributioa box above outlet invert due to an over:oadod or clogged SAS or cesspool. Liquid depth in cesspool l�'leas than`6"below invert or available volume L lass than 112 day flow. ItOquirod pumping more tl:an 4 tiruos in the lost year NOT due to clogged or obstructed plpo(s). Number of times pumpod 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 fort of a surface water supply or tributary to a surface water supply. Any portlon of a ooupool or privy is within a Zone I of a public well. Arty portion of a cosspool or privy is within 60 feet of a private water supply well. Any portion of a oasspool or privy is lass than 100 foet but groater thin 60 foot from a private water rupply well with no acceptabls water quLUty analysis. U the well has boon analyzed to be acceptable, attach copy of well wstar&rtalysL for coliform bacteria,volatile or1,•anic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 4/0 The Pam servos a facility with a deign flow of 10,000 ad or groawr(Large System) and the system is a si$niIIcant throat to public health and safety and the environment bo:ause one or more of the following condition exist: the system is within 400 foot of a surface drinking water supply tha rystam is within 200 l+et of a tributary to a surface drinking water supply tha rygUm is locatod in a nitrogen cansitive eras (Interim Weilhoad Pr•otoction Ara&(IWPA)or a mappod Zone II of a public water supply well) The owner or opers.tor of any such system sha.l bring the system and fa-cWty into full compllana with the Vvundwat¢r tr"twnt prov= roqubNments of 314 CMR 6.00 and 6.00. P1ocL a corwult the local regional office of the Department for farther information., r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property,A;i a,,.•:..; 68 Carla Road Hyannis ,Mass . 02601 Owner. Winfield D. Smith Date ofIwr, n5/2/96 Check if the ft:.!,-.-;ng haw been done: Zr,.Mping information was requested of the owner, occupant,and Board of Health. 2i of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates that period. La volumes of water have not been introduced into the system recently or as part of this inspection. rge plans have been obtained and examined. Note if they are not available with'N/JC' cility or dwelling was inspected for signs of sewage back-up. •-t em does not receive non-sanitary or industrial waste flow was inspected for signs of breakout. ' ^,n components, 9kuding the Soil Absorption System,have been located on the site. A/C4N, -^is tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or 0.rW of construction, dimensions,depth of liquid,depth of sludge,depth of scum. site has been determined based on existing information or and location of the Soil Absorption System on the .cited by non-intrusive methods. :'ity owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- :Aposal System. (revised 11P' 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Carla Road Hyannis ,Mass . 02601 Owner. Winfield D. Smith Date of Inspeotion: 5/2/9 6 FLOW CONDITIONS RESIDENTIAL: Design flow: f�+%`d'¢Y • Number of bedrooms: Number of current residents: Garbage grinder(yes or no):=es Laundry connected to system(yes or no):Y-4 S �r- Seasonal use(yes or no): /J j s ' ,5 ; I/ Olga Wa r r readings ' available: Last date of occupancy: COMMERCIALfINDUSTRIAL. Type of establishment: Design flow:_4/_-_jrallons/day Grease trap present: (yes or no)_kt9 Industrial Waste Holding Tank present: (yes or no)-lia-19' Non-sanitary waste discharged to the Title 5 system: (yes or no)" Water meter readings, if available: /)R Ing Last date of occupancy: OTHER (Describe) kfi Last date of occupancy: GENERAL INFORMATION PUMPING RYCORDS and of information: �. / to r Ufa iC System pump4d as part of' ion: (yes or/no)�7 It yes,volume pumped:�llon,E..L Reason for pumping. TYPE OF SYSTEM 1NSeptic 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) ROXIMATE A E of all components, date installed(if known) and source of information: �J 4 �I L°IG�Q �� Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddreae: 68 Carla Road Hyannis ,Mass . 02601 Owner. Winfield D. Smith.. Date of Inspection: 5/2/9 6 SEPTIQ TANK s (locate on site plan) Depth below grader Material of construction:LaConcrete_metal_FRP_other(e:plain) Dimensions: Sludge depth Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thiclmess: KJA Distance from top of scum to top of outlet tee or baffle:�1 Distance from bottom of scum to bottom of outlet tee or baffle: 131� Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: 'vim truat'.A'gooncrete_metal_FRP _other(e:plain) Material of co�. A Dimensions: AY scum thickness: /D Distance from top of scum to top of outlet tee or baffle: N� Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence?leakage'etc. No 60*1 (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address 68 Carla Road Hyannis ,Mass . 02601 Owner. Winfield D. Smith Date of Inspection: 5/2/9 6 TIGHT OR HOLDING TANY-95) (locate on site plan) Depth below grade: _ Material of consttuction:A60ncrete_metal_FRP--other(explain) 1 Nff Dimensions: N Capacity: N d pllons Design el:�allona/day Alarm lavel:, YU=1=i Comments: (condition inlet tee,condition of alarm and float switches, etc.) >� DISTRIBUTION BOX:,d�di (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.) a PUMP CHAMBER (locate on site plan) Pumps in working order:(yes or no) A> Comments: (n�condi�ion of pump cham�r, condition of pumps and appurtenances,etc.) CC •� (revised 11/03/95) 7 — PART C -- -• ---- ... : -SYSTEM INFORMATION INFORMATION (continued) Property Address: 68 Carla Road Hyannis ,Mass . 02601 Owner. I Winfield D. Smith Date of Inspection: 5/2/96 n jr SOIL ABSORPTION 8YSTEM (SAS):� -la rxp /.��dc/C C e 5;,/'Ve29 (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: leaching pits, number:, leaching chambers, number:0 leaching galleries, number:- leaching trenches, number,length: leaching fields, number, dimensions:_ overflow cesspool, number: I Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.) Loamy sand to medium sand;No signs of hydraulic failure;No signs o -ponding-All y�¢Ptat; nn is normal - Cesspool xds filled tocapacity. Cesspool aua o be omitted and the system upgraded to a title five septic system CESSPOOLS: (locate on site plan) ` Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: 0 �_ Dimensions of cesspool: d-1; �Yby Materials of construction: /V[;i°'eT� i- ,e[:XS Indication of groundwater: 01,tle. inflow(cesspool must be pumped as part of inspection) E 5 lgCl-A 6uE;;^e IH "/14 ! 'T /1- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to medium sand;_no sins of hydraulic failure or ponding; T e—ge ja+.i on i s nnrma l (laaspQols fled to capacity. The cesspoo s must be omitted and a new title five septic system installed. . PRIVY: !1/ (locate on site plan) Materials of construction: IV19 Dimensions: Depth of solids: A/* Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Al ll��lss9e!eITS (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddresr: 68 Carla Road Hyannis ,Mass . 02601 Owner. Winfield D. Smith Date of Inspection: 5/2/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: • include tier to at least two permanent references landmarks or benchmarks locate all wells within 100' Hyannis Water Company 775-oo63 DEPTH TO GROUNDWATER Depth to groundwater. 3 5 1 + feet methbd'of determination or approzimation: Hi gh on knoll. Installed system 2 5-2 7 ears ago. No water encountered when cesspoo s we Inspection. No water was encount€�8t-7z- when the cesspools-were (revised 11/03/95) 9 �� . .•t � SIC L i THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and •is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR R 15.340 and Section 13 0 f Chapter 21A of the as provided in 310 CM p General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the - ion of Water Pollution Control rrtnrirn•r�.T+- rnrrr.•rfrt..n.r...r..r,:•.-r-par:.rsn.-.�rrr..z r:--rcrrt.. __ ._ _ .. .. .�. _.. _ .r�•r.--r-.�rr�r-::.--.r-•F MOWN OF Barnstable BOARD OF HEALTH I SWISURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION {`A �/ F•••�••e-r••.-::e--.i:-�.--r+.rr-n•r.:m—:.-•.:r.—:n-r-r:Trt:.—e.-s+�r'-r-r.ne..ae rz'a - ssmn-emmrtsvzn'r+rrm..•rrrr•r.--r.-..n -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 68 Carla Road Hyannis ,Mass . 02601 ASSESSORS MAP , BLOCK AND PARCEL # Map 258 Parcel 39 OWNER' s NAME Winfield I?. Smith PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr, COMPANY NAMEJ.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City Stat• LIP COMPANY TELEPHONE 508 } 775 3338 FAX ( 508 � 790 18 . rsa•rfswsm.ress ee.o. �iaa.x ---�'��svQ 57 is CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . XXXXXXXXXSystem FAILED* The inspection 'which I have conducted has found that the system fails to protect the 'public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Si nature /tGCGy Date 5/7'l96 p g I % One copy of this c t,ification must be provided to the OWNER, the BUYER ( where applicable ) and the 110ARD OF 11HALT11. * If the inspection FAILED, the owner or "o erator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CNR !15 . 305 . Dartd .dnrr ,,e TOWN OFBSTABLE LOCATION lO S� .P�/� ��^ SEWAGE # VILLAGE / � A1I/7 /J ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0.1J7� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ?s (size) NO.OF BEDROOMS r3 . BUILDER OR OWNER 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 W kAJ 1� w p. 1'� O � 2I A O TO OF BARNSTABLE LOCATION SEWAGE # ��J YII.LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. s SEPTIC TANK CAPACITY LEACHING FACILITY: (type)070� (size) f NO.OF BEDROOMS (� BUILDER OR OWNER J./�ir/9�7�1 'li�� c7WB711 PERMPTDATE: ` 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 30O feet f leachi fali Feet Furnished by °� R b - � � � o � � `,�, �1u \ c � � �� r� • � J