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HomeMy WebLinkAbout0067 LONGVIEW DRIVE - Health 67 Longview Drive Hyannis a u - A= 251 Z 093 ° u o ° : ' , ° t: a : w ' r m ,, , a if AM ASK , , 'A - 53113 RED 10°!o P4 ,. n � u F/OV/Off, 9 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL R. , i APR 2 2 2003 TOWN OF BARNSTABLE HEALTH a OT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP r—,..,._,T Prcperty Address .' / ,.o�B PARCEL 210 Y MA - LOT - - Owner's Name: Owner's Address: C4_ Date of Inspection: a Name of Inspector: (please print r ` 10" Company Name: i Mailing Address: .0. .-`7r9St /� /} 8 Telephone.Number:�'Z .. .. .,, , ..CERTIFICATION STATEMENT_STATEMENT _. _. I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority �F ils Inspector's Signature: — ' Date: 03 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. �� p Notes and Comments ****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 ►n the future under the same or different. conditions of use. l Title 5 Inspection Form 6/15/20.00 page I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: , Owner:_ lov; o� Date ofInspection: 1,ypD,a a' 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 3.10 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. 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 staticwater 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: 2 Page 3 of.I 1 . ' OFFICIAL INSPE.CTI.ON FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ` 7 ' Owner: Date of Inspection: C. Further Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. L` 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 wilt 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 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: I r 3 ' J Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �yt/A Owner: Date of Inspection: 1,:1(jQ3 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 onsystem 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!/z dvy flow - Required pumping more than 4 times in the last year NOT due to clogged or obstructed p.ipe(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:I of a:public well. Any portion of a cesspool or privy is within 50 feet of a.private water supply well. Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15. 03,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correctthe failure. E. Large Systems: , To be:considered a large system the-system must serve a facilitywith adesign;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 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 questibn 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 31.0 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST layProperty Address: p Owner Date of Inspection: c� Check if the following have been done.You must indicate."yes"or"no"as to each of the following: Yes No ~Pumpirg information.,was provided by the owner,occupant,or.Board of Health Were.any of the system components pumped out in the previous two Weeks? Has the system received normal flows in the previous two week period V Have large.volumes of water been introduced to the system recently or,as part of this inspection? t/ 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 backup:? _ Was,the site inspected for signs of break out Were all system components,excluding the SAS; located on site f _ Were the septic tar►k manholes uncovered,opened;, and the interior of the tank inspected for the condition of sludge and depth of scum? of.the baffles or tees,material of construction,dimensions,depth of liquid, depth. � p _✓_ 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 Existing information.For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 C Page 6 of 11 OFFICIAL INSPECTION=FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 ,.( .egq(�2r/f A Owner: ' -% Date of Inspecti(n:�,�� II_—)(.9 Q/')0� FLOW CONDITIONS RESIDENTIAL �l Number of bedrooms(design): ,. 7 Number of bedrooms(actual): . DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: C Does residence have a garbage grinder(yes or no): (� F_ Is laundry on a separate sewage system (�ys or no _Q .[if yes separate inspection required] Laundry system inspected(yes or no):AZ Seasonal use: (yes or no):��1J Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):/ Last date of occupancy: , COMMERCIAL/INDUSTRIAO(t— 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 NFORMATION Pumping Records Source of information: Was 1systempumped as part of the inspection(yes or no): If yes, volume pumped: gallons=-How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _:Privy _Shared system(yes or no)(if yes, attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _.Other(describe): Approximate age of all compon nts,date installed(if known)and source of information: �Ov Were sewage odors detected when arriving at the site(yes or no 6 I Page 7 of 1'1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.-INFORMATION(continued) Property Address: Owner: b Date of Inspection: �4p, BUILDING SEWER(locate on site plan);/ Depth below.grade: F Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of Ieakage,etc.): SEPTIC TANK: r/ (locate on site plan) Depth below grade:: v?a V Material of construction: ,-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) Dimensions: 0,S.x r� Sludge depth: 19 ,6-0' 1 " �! , Distance from top of sludge to bottom of outlet.tee,or baffle f 7 Scum thickness:,-�- Distance from top of scum to top of outlet tee or baffle: 2 Distance from bottom of scum to bottom of outlet tee or baffle: �� How were dimensions determined: L/l Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels elated to outlet invert, evidence of leakage,etc.): _ 62 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.): 7 - 1 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM'INFORMATION(continued) Property Address: Owner: Date of Inspection: 3 TIGHT or'HOLDING TANK: ank 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 work_mg order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:-,Z'(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and dist-ibution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,e .): 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.): 8 Page 9 of 11 Z OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. t Date of nspection: (2(L-A ace;„"?00-3 SOIL ABSORPTION SYSTEM (SAS): t�(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ aching chambers,number: 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, etc i 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.): 9 Page 10 of 11 OFFICIAL INSPECTION-FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: e)2e c.P —0 0wner�4t,�/f / Date of Inspection: ( 07�3 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. a� a pu, yo 10 Page 1 l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r1 -S / Owner: Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water �'14 feet Please indicate(check).all methods used to determine the high groundwater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:. Observed site(abutting.property/observation hole within 150 feet of.SAS) Checked with local Board of Health-explain: Checked with.local.excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you.established the high ground water elevation: , �� 5 'e 11 Permit Number:. Date: Completed by: ,�J� . HIGH GROUND-WATER LEVEL COMPUTATION Site Location: !� ���✓ f�/ �; f/`d >°< Lot No. Owner: $ /� Address: Contractor: �19 " f , Address:. r �l% � % A91, Notes: � � STEP 1 Measure depth to water table to nearest 1/10 ft. ........................................................ ............:...t... .Date 3 month/day/Year STEP 2 Using Water-Level Range Zone and Index Well'Map locate site and determine: OA Appropriate index well.................... OWater-level range.zone ................... . STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index Well ........:..... ......... month/year • 1 STEP 4 Using Table of Water-Ievel.Adjustments for index well (STEP 2A),current depth to Water level for index well.(STEP 3)., and evel zone (STEP 2B)* determine Iwater-level adjustment-...........;..... .......... ................................. .. ........................ 7 STEP 5 . Estimate depth to high water by subtracting the Water level adjustment(STEP 4) from measured depth to water �� Z levelat site (STEP 1) .................::................. ......................................................................... Figure. 13.--Reproducible computation form. 15 1 < • � a 3 • � tom. } KS e E @I I J(i t i. TN. 4 sn � ' I TOWN OF BARNSTABLE LOCATION S >ew Ar. SEWAGE # VILLAGE ' � �� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I aid GAL/ f l LEACHING FACILITY: (type) ZI-1 L411 ®�S /(" J (size) /'O, Vd e_a�µ NO. OF BEDROOMS y BUILDER OR OWNER PERMITDATE: 1�6 © COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility t 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 /jCZ'r s s r � G Ili o ^ r � o` J �! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYicatiou for 30igpogar *pgtem Couttruction Permit Application for a Permit to Construct( )Repair(I®)Upgrade( )Abandon( ) LJComplete System C Individual Components Location Address or Lot No.6 Owner's Name,Address and Tel.No.r41//erg Assessor's Map/Parcel Gr�� ��`/G� ✓ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 'gel,to le4�9 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building,/���� -�No.of Persons Showers( ) Cafetena( ) Other Fixtures Design Flow 1`® gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /,_le© AV Type of S.A.S. ///A � s Description of Soil 4e ✓a e R Nature of Repairs or Alterations(Answer when applicable) e Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Bo d of Health. Signed Date 1l�✓�r� Application Approved by Date Alf-�e Application Disapproved for the following reasons U. Permit No. �_�1 � Date Issued No.A?j/'A0 Fee 'r � THE COMMONWEALTH OF MASSACHUSETTS `Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migogar *pztem Construction Permit Application for a Permit to Construct( )Repair( ►/)Upgrade( )Abandon( ) Cl/Complete System ❑Individual Components Location Address or Lot No. • Owner's Name,Address and Tel.No. � Lp Zvi c- v�v L�// Assessor's Map/Parcel7 G -/�J`�'/'�!f �/1��o ��//��/ /7�Z�/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Bor t® 40/// Ca�sT l-q Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinderl, Other Type of Building. No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank ,[S"eD 94 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /� 40 .0eaO// Date1ast inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with-the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this flogrd of Health. / Signed Date Application Approved by 1 Date �e.' AIL Application Disapproved for the following reasons Permit No. F � F7 Date Issued ---------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS Z'r�`dQ3 BARNSTABLE, MASSACHUSETTS (Certificate of (tompliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( t/jUpgraded( ) Abandoned( )by Z 5 at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Ps i e 01,"#V"- dated Z- �Z jj� : Installer Designer A, n The issuance of this p t sh 1 o be construed as a guarantee that the s ste will function a� 'esigrj O ,t Date Inspector i gip. -----------------�� �---Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogaf *pgtem on5truction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at 4 7 l d hA vie W All iex,%1,e and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this ermit. Date:_�/f` Approved by ' f 11&99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS), I, hk/7- f de hereby certify that the application for disposal works construction permit signed by me dated 1Z$i!4d` concerning the property located at /w /7/, Ge-VA11-'1116—' meets all of the following criteria: fa/The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. 6/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ff 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 There is no increase in flow and/or change in use proposed` Y There are no variances requested or needed t/ 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 /if method when applicable] the S.A.S.will be located with 250 feet of airy 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 c/ +the MAX High G.W.Adjustment !i / Z DIFFERENCE BETWEEN A and B 33 . 1 SIGNED : DATE: [Sketch proposed plan of system on back]. - q:health folds:art a w �Id,I ci ixU��Z 000 cP Fill%� �XiSf% �p . G�yg�edls i 5 �►j�ffl L°� !�Y`, r TOWN OF BARNSTABLE i LOCATION f7 ( �il��/IPrN . SEWAGE # � j VILLAGE �8i! yil`� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACEUTY: (type) (size)��rgio�3 /(o � (size) 10-<Vd NO.OF BEDROOMS y BUILDER OR OWNER PERMIT DATE: 1 Z6 7WO COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r t Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by C Z Oh _ 1 � i /� 7Vq