HomeMy WebLinkAbout0221 LONGVIEW DRIVE - Health 221 Longview Drive
Hyannis
A— 251 — 137
I
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CO?v1T,1ONti•TEALTH OF MASSACHUSETTS
Y= Y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
FC) DEPARTME?,.TT OF ENVIRONMENTAL PROTECTION
( TITLE
OFFIGLAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART .A
f
CERTIFICATION
Property Address:
h
Owner's Name:
Owner's Ad.dres
Date of Inspection: lwca
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Name of Inspect please print)
Company
Mailing Address: N
Telephone Number:. 2Q
CERTIFICATION ST>ATEMET
` I certiry'that I have personally inspected the sewage disposal system at this address and that the information reported
i
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 DE.P, ;
approved system inspector t3ursuant t0 Section 15.340 of Title 5 310 CMR 15.000). The system " -
PP P � . (
palsses
Conditionally Passes . i CL
N�eds Further Evaluation by the Local Approving Authoriry
1 s c l u
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InspectC 's Signature: Date:
, � t�
The syswm inspec or'shal sub zip z copy of f his inspection report to the Approving Authorit;� (Board of Health or.
DEP)'within SO days of con_pletina this inspiection. If the system is a shared system or has a design flow of 10,000
gpc or Beater,the inspector and the system o finer shall.submit the report to the appropriate regional office of the
DEP.`,The original hould be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority. C
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 in the future under the same or different
conditions of use.
Title.5- Inspection Form E/i ,%0.00 page 1
� f
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT
PART A
CERTIFICA_ION (continued)
Property Address: g ,j N&
Owner =/ %
Date of I spection: 7 ' a
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D
A. System Passes:
h ^V 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.nct 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 replacemer_t or repair; as approved b 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,arid'over 20 years old- or the septic tan_;(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or.ta_-ik 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 availabe. .
ND explain:
Observation ofsewage backup or break out or high s:atic water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, set-tied 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 thanA times a year due to broken or obstnuud 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:
Page 3 of I 1
OFFICIAL INSPE CTION FOR_IYI -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI ON FORM
PART A
CERTIFICATION (continued)
PropertyAddress• �"xa .
Owner:
Date of'I pection:
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 orthe environment.
I. 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
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 aseptic tank and soil absorptiomsystem (SAS)and the SAS is.within 100 feet of a -
surface water=supply or tributary to a surface water.supply,
The system.has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
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 :f the well eater an�iysis,performed at.a DEP certified laboratory, for coliform
bacteria and volatile orgaric compounds indicates that the well is.free from pollution from that facility and
the presence of ammonia nitrogen and rotate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria areiitarered: A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of. 11
OFFICIAL INSPECTION FORIMI :—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE_SEWAGE DISPOSAL,.SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: /
Date of 164pection: (p
D. System Failure Crite a applicable to all systems:
You must indicate"yes"or"no"to each of the.following P
for all inspections:
—
Yes Ngg
JI 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 Around.or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool .
Liquid depth in cesspool is less than 6 below invert or available volume is less than %day flow
_ e a_ Required pumping more than . times 1n.the last year NZ71 due to clogged or obstructed pipe(s).Number
/ of times pumped
J 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 `'Y p e
cesspool.o,.P ri is within a gone 1 of a. uGlicwell..
Any portion of a cesspool.or privy is within 50 feet of a.private water supply well.
Any portion of:a cesspool or•privyis.less than 100 feetbut areate.r 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 colifarm bacteria and volatile organic-compounds
indicates that the well is free from pollution from that.fa6lityand the.presence of ammonia
nitrogen and nitrate nitrogen is equal to cr:ess than : ppm, provided that no other failure criteria
are triggered. t.A co of the analysis.must be attached .o this
�g PY Y s form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CivIR 15.303,therefore-the system fails. The.system owner should contact the Board of
Health to determine what will be necessary to corectthe failure.
E. urge 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 follov,iha:
(The following criteria apply to large systems in addition to the criteria above)
yes 110
the system is within 400 feet-of a.surface drinking water supply
the system is within 200 feet-of a tributary to a surface drir_king 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 3.10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 1.1
OFFICIAL INSPECTION-FOR-Mf NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: gr
Owner. LZ�CU
Date of�,rII ection:
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
ZWere any of the system components pumped out in the previous two weeks ?
Has the system received normal lows in the previous two week period ?
ZHave large volumes of water been introduced to the systern.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 suns 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
ct£fhe baffles or tees, material of"construction. dimensions, depth of liquid,.depth of sludge and.depth of scum?
Was the facility ov/ner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems? .
The.size and loc4tion of the Soil Absorption System {SAS) on the site has been determined based on:
Yes no
Fxisrng information. For examble, a plan at the.Board of Health.
�! Determined in the _ie'd.(if any of the failure:criteria related to Part C is at issue approximation ofdistance
is unacceptable) [310 CYIR 15.302(3)(b)l
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'I'FIONI FORM
PART.C
SYSTEM INFORMATION
d
Property Address:
4 .
Owner.
Date,of. spection: j ?
V7� FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(design): Number of bedrooms(actual).: .
DESIGN flow based on 310:CMR 15.203 (for example: 11.0 Qpd x T of bedrooms):
Number of current residents: /
-Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):,�6.[if yes separate inspection required].
Laundry system inspected(y.*s.or no):/ o
Seasonal use: (yes or no.)-/V0 1
a
Water meter readings, if av 'lable (last 2 years usage gpd)): i
Sump pump (yes or no):NO � ' •
Last date of occupancy:
COMMERCIAL/INDUSTRIAL. /V/6
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
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:
Was system pumped as part of the nspection(ye or no): 0
If yes, volume pumped: gallons --How was quantity pumped determined? _
Reason for pumping:
TYPE F SYSTEM
eptic 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 approva:
_.Other(describe):
Approximate age of all components, date installed(if known) and sop rce of information:
a �96
Were sewage odors detected when arriving at the:site(yes or no)
6
.
Page 7 of l 7
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION:(continued)
Property Address: �---">
4 L�I
Owner:
Date of spection: '
BUILDING SEWER(locate on site plan) /Njr/�
Depth below grade:
Materials ofconstruction:—cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments (on,condition ofjoints, venting, evidence of leakage,.etc.): `
SEPTIC TANK: ✓(locate on site plan)
.Depth.below grade: _
Material of construction:�onc,.ete_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) t y
Dimensions: 1r X ( X
Slud2e,depth: 1,
Distance from top of 11 ge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle`.
Distance from bottom of scum to bortor outlet tee.or-baffle:
How were dimensions determ, ined:
Comments (on pumping recommendd"o s, in%et and outlet tee or baffle.condition, structural integrity, liouid levels
as elated to outlet invert evidence of leakage, etc.In }:
iJ 0
cut
GREASE TRAP:/j/(locate ori site plan) �� /`'[ -«-L %Z
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 oflast.pumping:
Comments (oil pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 1.1
OFFICIAL INSPECTION FORM—.NOT FOIEYOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C
SYSTEM INFORMATION(continued)
Property Address:.
Owner: a �°
Date of ection:
TIGHT or HOLDING TANK: G`tl,(tank must be pumped at time ofinspection)(loc.ate on-site plan)
Depth below grade:
I Material of construction: concrete metal fiberglass oolvethylene other(explain):.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alain 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: !/ (if present must be•opened)(_ocate on site.plan)
Depth of liquid level above outlet invert.. _e��'} i Grr'' hLdAo
Comments(note if box is level and distribution to outlets-Utal, any evidence of solids carryover, any evidence of
kale.into or out of box, etc.): ,
b
PUMP CHAMBER, (Iocate 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 Dumps and appurtenances, etc.):
3
I
Pate 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE UISPOSAL`SYSTEM INSPECTION FORM
PART C
SYSTEM INFOIZIMATIO.N (continued)
Property Address: LaaLey',�
a
Owner:
Date of pection: ? .'L
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type ..
leaching pits,number:_
leaching chambers, number:
Teaching galleries, number:
I ching trenches, number, l_enzth:
i
- � eachmQ 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 veeetation,
�,2—
O It
CESSPOLS��(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth'—top of liquid to inlet inven:
Depth of solids laver.:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no): .
Comments(note coed ticn of soil, sins oT hydraulic failure level of pondinQ, condition of vegetation, etc:): y
RIVY !� locate on site'clan
Materials of constructior_.:
Dimensions:.
Depth of solids:
Comments (note condition o soil: sins of hydraulic failure, level ofponding, condition of vegetation, etc.):
9
Page 10 of 1.1
OFFICIAL INSPECTION FORM ..NOT FOR VOLUNTARY ASSESSIMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FOI;UM
PART,C
SYSTEM INFORNIATION(continued)
Property Address: ���
A
Owner:
Date of pection: (� (j
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 buildino,.
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Page I I of I 1
OFFICIAL INSPI1C I'ION FOR'vI—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ? ,' t
f�.
Owner:
Bate of In• ection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet ' -
PIease.indicate check all methods used to detenninerthe high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Hea1_th-explain:
Checked with.local excavators; installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high groundwater elevation.
t
1I
Permit.Number: Date:
Completed by: -�
`HIGH GROUND-WATER LEVEL COMPUTATION
Site Ldcation: .j ' 3 '� �
Lot No.
Owner: U /01 Address:
Contractor. d-- -- Address:
Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft ........ ......... ................................................ 5
Date
month/day/year
STEP 2 Using Water-Level Range Zone:and Index Well Map locate,,,:,,
site and determine -
O,Appropnateindex-well ,.,.-`. .................
OWater level range zone .......................................
STEP 3 Using rrmonthly`report '':Current
Water:Resources'Conditions -
determ�ne current depth'to
Vvater.leve for iridex}wehl
month/year
STEP 4 Using Table of Water level Adjustments
for.-index.well=(STEP 2A), current depth' »
to water-level formdex=well-(STEP 3),
and water level zone (STEP 213) _
determine water-level adjustment ....... .
STEP a, Estimate depth,to-high water
by subtracting;the water-
level adjustment (STEP 4)
from measured depth to water
level at.site (STEP 1) ................. .......:.
Figure 13.-Reproducible computation form.
15
_TOWN OF BARNSTABLE
LOCATION 2' LDS . U/ems SEWAGE #
VILLAGE ' rASSESSOR'S MAP& LOT Z Si37
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / DD
LEACHING FACILITY: (type) 170�X/S�Sy?hea�l .. (size)
NO.OF BEDROOMS 3
BUILDER OR �WNERI
�- 26-�d
PERMTTDATE: COLIANCE DATE:
�. MP:. �,=�=�
Separation Distance Between the:
Maximum Adfusied Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site orwithin 200 feet of leaching facility) Feet
Edge of Weiland and Leaching Facility(If any wetlands exist
within 300,feet of leaching facility) Feet
Furnished by
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g6No. Aw _ Fee
THE COMMONWEALTH OF MASSACHUSETTS �,
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for 33ig;pozat *pztem Congtruction Permit
Application is hereby made for a Permit to Construct( )or Repair(V)an On-site Sewage Disposal System at:
Location Address or Lot No. �7 Z�
� Owne;Name,Address and Tel.No.
Assessor's Map/Parcel e//7er`Z Ile ,,
�Z Gad ,rOr^ c�yfi�rvi`/e
Instper's Nam ,Address,and Tel.No. Designer's Name,Address and Tel.No.
7 fv�9
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder vtp
Other Type of Building /1' No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow %l gallons per day. Calculated daily flow 3 P gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
N4ture o Repairs or Alterations(Answer when applicable
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 issue by o d of He
Sign Date
Application Approved byZ9 ® Date
Application Disapproved for the following re 69
s
Permit No. Date Issued
q1
4/0
No. , Fee
THE COMMONWEALTH OF MASSACHUSETTS
} /PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
r
Rpprtration for Mts;paal Opgtem Congtruchon Permit
Application is hereby made for a Permit to Construct( )or Repair( an.On site Sewage Disposal System at:
Location Address or Lot No. 7Z
0 Ille el Owner's Name,Address and Tel.No.
Wef F C 1AZ
Assessor's Map/Parcel
G Zz
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
for
Z_
Type of Building:
° Dwelling No.of Bedrooms Garbage Grinder vtlp
Other Type of Building P-6 J&Li9Ge No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3310 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
'P
Nature of Repairs or Alterations(Answer when applicable) d !1. '675 !��
i
IF'
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 by thi . oard of Health.
Signe Date
Application,Approved by Date ,42
Application Disapproved for the following re o s
--Permit No. Date Issued
1 ---------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
1
BARNSTABLE, MASSACHUSETTS
r
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(w/)on
by Installer 21/7S /_O_ �` Ci"s�-SrLrfrc ic>�a
at "7 7 / bra 11/e,4, Y/' ����i',N/J%f�G has been constructed in accordance
with the provisions off�of the for Disposal System Construction Permit No. dated
Date Inspector
i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
l ——————r——————————————— -'———————)——— -,—/ ——
q-jlNo. t / / Fee
I Lill
k THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE., MASSACHUSETTS
Miopo!5ai 6p.5tem Con9truction Permit
Permission is hereby granted to l?ef tee ®Ze eti//,/r %Gn Al
to construct( )repair(van On-site Sewage System located at No.#
lly
street
and as described in the above Application for Disposal System Construction Permit. '� I
No. I yate
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special c•nditio s. j
All construction must a completed within three years of the date below.
Date: t'I/� Approved by -r����
t Board of Realth
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION I,EIt1111'I' (WI'I'II0UT I)ESIGNEI) PLANS)
erg j` �,hereby certify that the application for disposal works
construction signed ned by me dated !? Zo �!� , concerning the
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property located at ze y lo/ . G�rIS�/"Vi%1� meets all of the
llw&/
following criteria:
d here are no wctlands within 300 feet of the proposed septic system
There are no private wells within 150 rect of the proposed septic system
y he observed groundwater table is 14 rut or greater below the bottom of the leaching racility
There is no increase in flow and/or change in use proposed
r n variances requested or needed.
There are o
SIGNED : —4w
DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan or the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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