The URL can be used to link to this page

Home My WebLink About0028 GOOSE POINT ROAD - Health 28 Goose Point Road s Hyannis A'= 252 -�049 rah .t -B V . S Commonwealth of Massachusetts p aSa r 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments Property Address Ow ner Ow ner's Name /yJ Information is 0,. (00 required for everyArA-041 --- page. City/Town State Zip Code Date Ins tlon Inspection results must be submitted on thisform. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. IOng out forms A. General Information fvng out forms on the computer, use only the tab 1. Inspector. key to move your cursor-do not /M C O 1 -ems ll use the return Name of inspects _ r}� Company Name Company Address �• .Gas��G� Qty/Town �,ro e) a�o _779� State /'O 00P zip code 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 16.340 of Title 6(310 R 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Irnspecto's signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health of 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. t5i,ts,W3 T11e50ffidal Irsom6cnFcrm SubMace Sewage Disposal SMm-Pge 1o117 Lo "VS Commonwealth of Massachusetts Title 5 OffiE.ial Inspection Form Subsurface Sewage Dis 6saI System Forth - Not for Voluntary AssessmentsIF. / C 00-5e ✓%i �- �d Property Address �J✓1-PVI Ow ner Ow nees Name /� r Information Is / avol4ts required for every page. Cityrrown State Zip Code Date of Kslpecdon B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) Syste se ss: 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 ex ain. 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 Ka Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): tare-W13 Tide 50fficial Ina pee ten Form SubSW ace SoVage Disposal System•Page 2 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 02 6-oose �'"o 1 o f- led Property Address ON ner information is �^�Hers Name required for every State page Ckyfrown Zip Code Date of ns lion 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 mannerwhich 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 15re•9N3 Tito 5orfid s m � alipeceFormSubsuiaceSewageOlspoS)Wm-PageU 1T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Cz� Goon 1,20�� f %� Property Address ''^w Ow ner ON ner's Name iMormation is G 0 V7 1,( � 0,)6 6 0 requved for every page. Cityrrown State Zip Code Date Ins tbn B. Certification (coat.) 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 El Liquid depth in cesspool Is less than 6" below Invert or available volume is less than%day flow are-an 3 Tide s ofead ire pocdoo Form Suboulaw Sovrgo ascoW System-Page 4 of 17 Commonwealth of Massachusetts f� 0 U Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments / CXg GOOSE Property Address � (240 v7 Info ner ON r>er's Name Information �o�(G 0 �S irdormrmation is /,��y)1 f required forevery i State Zip Code Date fIns tan page. CitY/Town 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: ❑ E3,/ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑y/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ LT Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ E2""� 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 analysts, 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 ate triggered A copy of the analysis and chain of custody must be attached to this form.) D ❑/ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00 Gg pd. ❑ The system ffils. I have determined that one or more of the above failure criteria exist as described in 310 CM R 15.303, therefore the system fails. The system owner should contact the Board of Health to deterrnine what will be necessary to correct the failure. 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 sensitise 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. 'f itle 5 pfGciN IrLa poetlon F arrt SubevlaM SavapO DiS000d S1fam•P290 5 Of 17 Sm-Y13 r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C7:14 8 Goose j o f V7.7L Property Address II Vi0�1�✓J Ory ner Owner's Name information is c,✓► 00Z 6 6 d required for every --- page CitylTown State Zip Code We o(lnsp6efion 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 ❑ Ly ere any of the system components pumped out in the previous two weeks? ❑ as 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 NIA) 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)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): f9re•3M 3 Me 5 0ffwiel Ins poe bon f am SUtrA0eoe SeMage Disposal System•Page W 17 Commonwealth of Massachusetts yjTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for voluntary Assessments Property Address /) I Cw ner Ow ner's Name information is a n requiredforevery '—"—'�' State Zip Code Date of hispection page. Cityrrown D. System Information Description: 1500 6-4/6, ��o ec %9 N 1✓ �1 0tf4l�b64 *0'7 . zc) M T_e 14 6 60� . CU Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) ,^ Laundry system inspected? ❑ Yes B No Seasonal use? Yes ❑ No Water meter readings, if available past 2 years usage(gpd)): Detail: Sump pump? ❑ Y No Last date of occupancy: Da e Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: tyre•3H 3 Tito 50Mcial Irspecton F orm subsLeam sev age oisposei System'Pago 7 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a� GooSe iLol ' f- Property Address Q av ner C)N ner's Name O� 6 6 O info rmation is �0 0/regiredforevery — P�yffown State Zip Code Date of;v— page. D. system Information (cunt.) Last date of occupancy/use: Date J Other(describe below): General lnforrnatlon Pumping Records: Source of information: d part of the Inspection? El Yes No Was system pumped Kyes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: 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) rat Innovat the current on and ❑ maintenance contract technology.obtained ed from system owns) and apcopyi of latest maintenance contract (t inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): rise s omcial irs pectlon F orm subsuf ace Sewage Disposal sp"m•Page 8 of 17 t5m Y13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a (TOoSe 01 Property Address A �OyB�I Cw ner Om ner's Name / - information is Gr vl vt r S �� 6� required for every — page. Cfty/Town State Zip Code late of Ins tion D. System Information (cunt.) Approximate age of all com nents, date installed (if known) and ource of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): C;?- Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: feet 7e,a construction: concrete ❑ metal [Ifiberglass ❑ polyethylene Elother(explain) 9 tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No � X /o Dimensions: Sludge depth: tyre,3h 3 Title 5 official Ire pec Cm Form SubsLrf xe Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� oos� �, � � Property Address Owner Ow ner's Name j information is q.vt N 15 f required for every State Zip Code Date of tnspelbtion page. CRy/rown D. System Information (cons) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle —,SG W Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): u✓b r ✓1 �I�T 4ee ��, d0C) C0^ j/ 7iot, 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 t9ns-Y19 Tloe5O W tropecdcnFvm Subxrlaw SawepeDicpasel SyeWm•Va®e 10d 17 a Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for voluntary Assessments C�.r G00,5.e, 4- Property Address O�IpvJ Owner Ow Hers Name information is �� required for every Me. (Ityrrown State zip Code Date of s tan D. System Information (corn.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, wAdence 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.): i •Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t&ns Yi3 Title50ftidaltspectmForm Sutsurtace Savage Dispasal Sysmm•Page tt a 17 l� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Go os-p— Property Address I 1�0✓�P ✓1 ON ner ON ner's Name information is s / U ( 6 D 1 required for every page. City/Town State Zip Code Date ofinspei6tion D. System Tinformation (cont.) Distribution Box (if present must be opened) (locate on site plan);_. z: V,e 4 Depth of liquid level above outlet invert 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.): !�ve'/ 1A10 Sol )s e-,Lf 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: t9n,Y13 T050ffld81 lnspecknFonn Subsurface Sewage Disposal S)slam•Page 12 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for voluntary Assessments C�61 P 7L Property Address /4 in! nerrm � Oiv ner's Name Q alfomlation is requlred for every page. City/Town State Zip Code We oYMpkWn D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number. leaching trenches number, length: 6 C ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativetaltemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SO 4,CG✓i G �o, l lQ� Q H C, l v Alt ✓�S o Cb 41 // c -7<, 11A r1 , 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 t9n,y13 7&50ftial inspoctlonForm Subsurtace Sewage0lsposal System-Page 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection (Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p C�g Grouse /4/0 � Property Address 4 10✓gyp vI ON ner ON ner's Name Infomlation Is C A V)ij / '/T 0 ) 6 6 o requaedforevery H(I page. City/Town State Zip Code We of IfispeAn 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.): Sm-aryg TW950ftial InspecEmForm Subsutace SewageDispcsal Slatem-Pape 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments az9 gcj- Property Address info ner ON r>er s Name /yj � / information is G✓1�f.f �//� required for every _ --- page Cfty/Town State Zip Code Date of spe lion 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 lic water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately J � Ec vn A3 t5m,Y13 Tile$Olfltlal InspecOm Form SU0SlrtaW Sewage OlSposel System-Page 18d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 Property Address ON ner oN ner's Name /� n Information I. G✓1✓// / '/4 requaedfor every page. Cityy/Town G71State Zip Code We of lnspec'on D. System Information (cont.) Site Exam: i ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / / /fi/Q v'-e— Estimated depth to high round water. p 9 9 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) a/ 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: 0 Cl �/F s S S is o�L 4 /o U N Before filing this Inspection Report, please see Report Completeness Checklist on next page. 18B-3M 3 Tito 50MCial Inspecton F art[SubSW We S"o DispoS81 System-F'age 16 d 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address A Kth QN ner ON nets Name �, infom�tion is G✓t I S /" ��rl j¢ doh 6 6 D /fir feQ e. �Y forevery /Town State Zip Code Data Me. E. Report Completeness Checklist ,_,"pection Summary: A, B, C, D, or E checked L�'tnspection Summary D(System Failure Criteria Applicable to AJI Systems)completed S�em Information—Estimated depth to high groundwater Sch of Sewage Disposal System either drawn on page IS or attached in separate file 06,Y13 rmo sommal ftpac*MFarm&ftVfW0 SWA*AD SYS*M'PQP 17 d 17 i ��,t�►-� vATA ,5IW(,LE FAMIL`( FLAI,-L Ot,l 13AG4- 4lEfzE-� I Flo GA¢►3AL� C�I�.tv�. FLOW = 3 x I I o = 33 o. 9 usp- 1500 GAL. ___ ..__._..........__........._._....�._ � �pax ,4T7pLacAT1oN AAA App oewno►-1 AVZA ti�516 N 51-C;r AAA �a x 2.k z = z 7 2 sF. -AI L OF LEA64�1►J - Tmt=X� tzoTTOM AZeA = 6OX q = 2q0 S•F. b, _ 98.5 lorAL A124 s 5 1 2 O��- 15' I c%z P`'r Ga-r> + pEce/oL t�AnN 2m L 5 l"�INc s-raN C za►tcE�3 ' MAX /g-�z 5Toi1E SOIL aAi j rn �.x 2E�A• __ 4' OFA� 1y 2 �I4-I'�z STaJ� �HOF PETER atcElnan P CIV!-I Or BAXTEa cr No :. 7F• A — E L-5A,?t 141 s� f Lr TVCW,N �u B gr7 4 (=,co z -45 • - ( SQfIG �. el" Txw. 9'17 99.9 7 T32 " S ' • � `G�V ELF P�oF 11�- a�. PLOT PLA�1 Z8 aCDSL twoItxy 2pPC7 �.lo"JiA-ct2 Ln��TIl Cc-r.�T:✓�Zy� `�� M�.sS IP-8788 Xf-; .56ALF-- AS rsoTT----D DA1 t-*- N 0 V-4 9g • f 120�OSED I 1'11=`/ 'f'NAT '1"N E �w c-��Gc SFtOyc/f`l �LAI�I IZ�.Eh1C�- 4+aawF .4 CAMPL`!S W IT-k -7 4E Slt)E-U E AIlp �A,,,A-r.3�C- 2y 9 '1�r�6�1r \Z zz Gv- zwoi1zemr T VF '1'14E ToK/N OF Mp,n 2S2 PAP.CZL 0A9 13,�rz�,� STii~6�EA�b t s *10 - L TED w I r41 N �P6uAl. FlsvD NAZ1\l�,b ZdNE, �AKT Q- HyE 11.4 do✓. ,II49& G c-� o5TE2vILL.+� MM4, ol-"F52rS VVoM $V 11.D1 t• 5 NOT" S E USED Ttb 6rTAbu sl.y PRO'pEa r,-/ LiIJES, i i I TO OF BARNSTABLE 1 LOCATION -g °�s� o�'� 7 SEWAGE 14 ^ 6 9 VILLAGE "/"4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.T�I�-g 1, G� �/- �/� SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) Y 6-,!52 x _vZ (size) ell NO.OF BEDROOMS _ _ /�/ _ BUILDER OR OWNER Cro GLr� T� z�i h e F C k' PERMITDATE: OMPLIANCE DATE: L 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 206 feet of leaching facility) �- Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin faci 'ty) Furnished by L Feet �.jo ! V\ i f I �- ve Car' vd