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HomeMy WebLinkAbout0085 KELLEY ROAD - Health 85 KELLY RD., HYANNIS ° ~l ° 1 ° r(N A ° f ° if • o I If l . 6, Aj COMMONWEALTH OF MASSACHUSETTS 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 o19.7 - a-c- Property Address:-85 K%Iiy Road Hyannis, MA. 02601 Owner's Name: Ronald Corbett Owner's Address: SAME Date of Inspection: 08/10/2006 Name of Inspector: (please print) Brad J White Company Name: Windriver Enviromental Mailing Address: 107 N. Main Street Carver,MA 02330 Telephone Number: (508)-866-2576 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information,re,ported, below is true,accurate and complete as of the time of the inspection.The inspection was performed based od 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: ! X Passes --- Conditionally Passes c;; Needs Further Evaluation by the Local Approving Authority .. . Fails Inspector's Signature: ate: 08/10/2006 The system inspector shall submit a copy 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. Notes and Comments .System Passes. Recommend zabel filter and build up on outlet end of tank. i ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 Kelly Road Hyannis, MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: System passes.Recommend regular service. 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. Answer yes,no or not determined(Y,N,ND)in the 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. 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 of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Titles G Inencrtinn Fn,,,,�./1 V7Mf1 2 i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 85 Kelly Road Hyannis, MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 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(l)(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 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 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. 3. Other: Title G Incnartinn Fnrm Oil';nnnn 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 85 Kelly Road Hyannis,MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— 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.] —NO_(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. 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• 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) yes no _ the system is within 400 feet of a surface drinking water supply i 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. i Titles G lnenortinn P-Ansi1nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Address: 85 Kelly Road Hyannis, MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? I _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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 ? _X _ 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: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. X_ _ 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)] T41. G 1-...t;-lr- Ail-VIMO 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 85 Kelly Road Hyannis,MA.02601 Owner: Ronald Corbett Date of Inspection: 08/101'2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):3 DESIGN flow based on 310 CMk 15.203 (for example: 110 gpd x#of bedrooms): 330gpd Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): 173.42gpd Sump pump(yes or no): NO Last date of occupancy:Current COMM ERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd - Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: NO Was system pumped as part of the inspection(yes or no):' If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _ —Single cesspool Overflow cesspool _Privy r No.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 of all components,date installed(if known)and source of information: System was installed approx 7 years per as built plan of septic system Were sewage odors detected when arriving at the site(yes or no): NO Titles C Incr t;n Pn 411 1;iInnn 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: 85 Kelly Road Hyannis, MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 BUILDING SEWER(locate on site plan) Depth below grade: 52" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Building sewer is in good condition. SEPTIC TANK: X (locate on site plan)(Inlet has riser 4"below grade) Depth below grade: 40" Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) j Dimensions: 10'-6" x 5'-8" x 5'-2" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness: 1 '/2" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): tees in good condition.Tank is structurally sound. No evidence of leakage in or out. GREASE TRAP:_(locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 Kelly Road Hyannis,MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 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/day Alarm present(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: X (if present must be opened)(locate on site plan)(49"below grade) 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 is level and distributing evenly.No evidence of solids carryover.No evidence of leakage in or out of the box. 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.): T41. 1; G,.,-..,All';i)nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C a SYSTEM INFORMATION(continued) Property Address' 85 Kelly Road t Hyannis,MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Ph Type _ _leaching pits,number: _X_leaching chambers,number: 4 Infiltrators 30' x 1V x 2' leaching galleries,number: leaching trenches,number, length: leaching fields,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, I etc.): Soil is dry. No evidence of hydraulic failure.Vegetation is normal. No ponding on the surface. 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 or no): 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.): Talc G incnortinn'Trrm�ii�i�nnn 9 Page 10 of I 1 � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 Kelly Road Hyannis,MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 SKETCH OF SEWAGE DISPOSAL'SYSTEM Provide a sketch 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. 1 V (31 22 ly 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 85 Kelly Road Hyannis, MA.02601 Owner: Ronald Corbett Date of Inspection: 08/10/2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 8'+ 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:4/27/99 _X_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: No indication of groundwater at 8'+ Per local topography.Taken from as built plan as well which indicates no groundwater @ 9' plus. A Title V inspection is often misunderstood to suggest that we are conducting a complete inspection of your system. A Title V inspection is limited to determining if, at the time of the inspection,the existing septic system is functioning. The State of Massachusetts has outlined specific tests that are to be performed, which will be completed during your Title V inspection. However, a Title V inspection, and the inspection that Wind River Environmental is performing hereunder,does not evaluate if the system was installed correctly,has been engineered in accordance with state and j local regulations, or whether the system will continue to function in the future. It also does not evaluate whether the system would meet the past,current,or future Board of Health or State DEP regulations. A system can pass Title V but still not meet state or local requirements or be suitable for continued use. If the customer would like a complete inspection of their system, including an evaluation as to the design and suitability of your system,Wind River Environmental can provide a quote as to the cost of such services. As well,Wind River Environmental strongly recommends �. persons interested in buying a home to have a full and complete system evaluation before purchasing a new home. A new home buyer should not rely on a Title V inspection in determining if the system will function in the future, and instead should commission a complete system inspection. T41. r, 1„c„P,.6—F­4n«')nnn 11 TOWN OF BARNSTABLE LOCATION SK-eLLi5j2 SEWAGE # CM7- VILLAGE d-4(4ww S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHON_E NO:, fidia / (-AQC S i-prm(- SEPTIC TANK CAPACITY /J 5 ICU LEACHING FACILITY: (type) N�x�l CuD�i I Aw- (size) f )cc-)l NO.OF BEDROOMS-- BUILDER OR OWNS w PERMITDATE: /' ' 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 O I v 1 � T> (A => t O No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for &gogaf 6pgtem Congtruction Vermit .Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Nomplete System El Individual Components Location Address or Lot No.7S I n-L. Owner's Name Address and Tel.No. Assessors Map/Parcel o ���j� Installer's Name,Address,and Tel.No. UU Designer's Name,Address and Tel.No. ih► cA9 10, 04 �A. � Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �� UvIJ Type of S.A.S. Description of Soil k s Nature of Repairs or Alterations(Answer when applicable) tS9VTi v2AiA 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 is o ,•/�`��Signed a Date Application Approved bytn�_�Z� Date Application Disapproved for the following reasons Permit No. Date Issued r No. ' t `:k a' 4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ZUBLIC HEALTH-DIVISION =TOWN OF BARNSTABLE, MASSACHUSETTS, Yes ZIpprication for Zigogal *pgtem Congtruction Permit 'Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Nomplete System 0 Individual Compo pents Location Addressor-Lot No.,,;;-,s r� �- / rr,,,t,-<,S Owner's Name Address and Tel.No. Assessor's Map/Parcel / C._0 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. y Type of Building: 2 Dwelling., No.of Bedrooms 7 Lot Size sq. ft. Garbage Grinder(­ ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures C, Design Flow3 d allons per day. daily flow 3 / �'- ' g p y y gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil /4,ey Sa L� Nature of Repairs or Alterations(Answer when applicable) 04D -SEA d C rvd-1- Ov2 c' s L r4 U 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 Certify- t cate of Compliance has been issu hisrealt Signed a Date Application Approved by o Date Application Disapproved for the following reasons Peftn No. _._ Date Issued �. THE:COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( )Upgraded (<I< Abandoned( )by at I u.VL has n constructed in accordance with the provisions of Title 5 and the for Dispo al System Construction Permit No. dated Installer 1 Designer The issuance of this permit sI of be con tr�ueda s a guarantee that the systemAll un tion as desi n/4d' v Date p w Inspector y 074 g .. — --------------------------------- No. , � AT --` —.� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS r3[gpo5W *pgtem (Congtruction permit Permission is hereby granted to Construct( )Repair/V<Iuz rade( )Abandon( �) System located at Gv�.tRl 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 7m �se com feted within three years of the date of i pe it.. ` Date: Approved by �� /�� X��Gl/f� - 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) -r� r�S. I, , hereby certify that the application for disposal works construction permit signed by me dated , - , , concerning the L property located at `� meets all of the Mowing criteria: LA/The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system / There are no private wells within 150 feet of the proposed septic system ere is no increase in flow and/or change in use proposed There are no variances requested or needed i I The bottom of the proposed leaching facility will not be located less than five feet above the, maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] -,e S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ✓. ' B) G.W.Elevation o) +the MAX.High G.W. Adjustment. _ D DIFFERENCE BETWEEN A and B �. SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cen .� ����� i.I 1 � 5 .;,, � e S i� . . � /:'