HomeMy WebLinkAbout0405 MITCHELL'S WAY - Health jrrMITCHELLS WAY, HYANNIS
291-015
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TOWN OF BARNSTABLE
/it� SEW_ ,AGE #,' T
VILLAGE_ ASSESSOR'S MAPj& LOT6 jam_
INSTALLER'S NAME & PHONE NO. o.1 ,6 77 S
SEPTIC TANK CAPACITY / So o 14( `
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LEACHING FACILITY:(type),?,4tv.e}Ai)ZeQS (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER Ol.C6WNE IeO
DATE PERMIT ISSUED: / Li-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ✓
ZIppYication for 3Digpoga1 *pztem Construction Permit
Application for a Permit to C nst ct( )Repair(grade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot N '-?"Pk et/S 149V Owner's flame,Address and Tel.No.
Assessor's Map/Parcel 71 q( — 01,
Installer's Name,Addre)k V WA� O Designer's Name,Address and Tel.No.
350 Mdin Street A111+
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 3 3® gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /,�dc� Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /JD a �---
�
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 ' ed by this Board of H akh./?
Signed ( Date
Application Approved by 0 Date
Application Disapproved for the following reason
Permit No. Date Issued
No. .. a Fee -�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpplication for Xkzpo al *potent Congtruction Permit
Application for a Permit to Construct( )Repair(10ruop grade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot N0. ""d'f�r f��e�f§. A1/ Owner's Name,Address qnd Tel.No.' #j
Assessor's Map/Parcel
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of -�
Installer's Name,Address';. d�1�0CANCO Designer's Name,Address and Tel.No. r
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350 Main Street 'lot/
'
Type of Building:
Dwelling No.of Bedrooms +`��� Lo(,Size sq.ft. Garbage Grinder( )
'Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design.Flow `30 gallons per day. Calculated daily flow gallons. 3
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 4 d0 Type of S.A.S. 27/7 4
Description of Soil A
i
Nature of Repairs or Alterations(Answer when applicable)
/i :<
Date last inspected:
Agreement: M '
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 this Board of H afth.
Signed t) A Date //` 4-9
Application Approved by o i Date
Application Disapproved for the following reason'
Permit 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( )
Abandoned( )by
at SDI f' h s b Astructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. r
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date -7 Inspector
--- n �7- --------------------------- —Fee " .
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS
Digpogar 6potent Congtructton Permit
Permission is hereby granted to Construct( )Repair(-_. -Upgrade( ) bandd/on
System located at .. t 1 4 Y p
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:Constructio m st be completed within three years of the date of i� it /
1
Date: ! Approved by f `-�Jl. 9
U
10/9/97
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
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed•by me dated concerning the
property located at. � VUl t` ne,�fs �,aJ,�-sue meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
•, 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 ✓
• There are no variances requested or needed. ✓�
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 7 3
B)Observed Groundwater Table Elevation(according to Health Division well map) old• S
SIGNED: �'1 �a.u�-., DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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SEPTIC -SYSTEM DESIGN
D ,� , ,. GAS/DAB'
.� RZDS AT . G /D '/.8�
sZPTIC TANK:
.,$ . GAL/DAB' x 2 DAYS = GAL
USE /Soo GALLON SK.FTIC TANK
LEACHING _ ° A.'
USX S Ili FILTRATORS HAXIMI ZER CHAN19E
'ITH 4' Off' STONE ALL AROUND (W x If x Z. 11Jr
SIDX .AREA: 30 + 11 2 .x2 = 164SP (.74) _ /
DAY
CAPACITY __..-
GAL/DAY
i TOWN OF BARNSTABLE
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LOCATION::^y /� 2�/_(__ �t/JPl/ SEWAGE
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VILLAGE y.4hh i S ASSESSOR'S 'MAP:'-6z LOT. '�
INSTALLER'S NAME 6z PHONE NO. 16 77 S= o2kUU .
SEPTIC:;TANK CAPACITY / Sam G°-4K -
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER O OWN XQ
i
DATE PERMIT ISSUED: 11 Li - f
DATE COUPLIANCE ISSUED: 49 ' 7
VARIANCE'GRANTED: Yes No
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Commonwealth of Massachusetts 9
Executive Office of Environmental Affairs do
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Department ®f RIC IVEP
Environmental Protection 1997
William F.Weld OWN W
Goremor - ARNSTAB
Trudy Coxe HDEPT LE
Secrelery'EOEA ,`
David Struhs 350 MAIN ST W YA
Commissioner , W.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP#291
PAR#015 r+
PROPERTY ADDRESS: .1rNitchells Way, Hyannis Ruth E. Williams Family Trust
DATE OF INSPECTION: June 25, 1997 c/o United States Trust Co.
NAME OF INSPECTOR James D. Sears 40 Court St., Boston MA
COMPANY NAME, ADDRESS AND TELEPHONE NUMBER:
A&B CANCO, 350 MAIN STREET,WEST YARMOUTH, MA 02673 (508)775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on
my training and experience in the proper function and maintenance of on-site sewage disposal systems. The
system:
PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
X FAILS
Inspector's Signature: Date: June 27, 1997
The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the
inspector and the system owner shall submit the report to the appropriate regional office of the Department of
Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving
authority.
INSPECTION SUMMARY:
Check A, B, or C
A] SYSTEM PASSES:
N/A I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If
not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,
or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced
with a conforming septic tank as approved by the Board of Health.
(REVISED 11-03-95)
One Winter Street Boston, Massachusetts 02108 Fax(617)556-1049 Phone(617)292-5500
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address: 450 Mitchells_Way, Hyannis
Owner: Ruth E. Williams Family Trust
Date of Inspection: June 25, 1997
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system
will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
4
_N/A_ Conditions exist which require further evaluation by the Board of Health in order to determine if
the.system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC
HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A
MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public
water supply well.
The system has a septic tank and soil absorption within 50 feet of a private water supply
well.
The system has.a septic tank and soil absorption system and is less than 100 feet but 50
feet or more from a private water supply well, unless a well water analysis for coliform bacterial
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.
3) OTHER
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 450 Mitchells Way, Hyannis ,
Owner: Ruth E. Williams Family Trust'.;..
Date of Inspection: June 25, 1997
D] SYSTEM FAILS:
X I have determined that the system violates one or.,more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board.of Health
should be contacted to determine what-will be necessary to correct the failure.
Y Backup of sewage into facility or,system component due to an overloaded or clogged SAS or ..
cesspool.
x '
Y Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool.
Y Liquid depth in cesspooleis less than 6"'below invert or available volume is less than 1/2 day
flow:
s
N Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipes).."
Number of times pumped
rc
,N Any portion of the Soil Absorption System, cesspool or privy is below the high
groundwater elevation:
N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
N Any portion of a cesspool or privy is within a Zone l of a public well.
N Any portion of a cesspool or privy is within.50 feet of a private water supply well.
N 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. If the well has been
analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile
organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
.. NIA The,system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the
system is a significant threat to public health and safety and the environment because one or
more of the following conditions exits:
the system is within 400 feet of a surface drinking water supply ,
the system is within 200 feet of a tributary to surface drinking water supply
s . the system is located in a nitrogen sensitive area (Interim Wellhead Protection A"rea(IWPA)
or a mapped zone.II of a public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater,treatment program requirements of 314 CMR 5.00 and 6.00. Please,cons uIt the local regional office of ,.
is the Department for further information. a
< F ,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 450 Mitchells Way, Hyannis '
Owner: Ruth E. Williams Family Trust
Date of Inspection: June 25, 1997
Check if the following have been done:
N/A Pumping information was requested of the owner, occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the
system has/has not been receiving normal flow rates during that period. Large
volumes of water have not been introduced into the system recently or as part of
this inspection
N/A As built plans have been obtained and examined. Note if they are not available
with N/A
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow
X The site was inspected for signs of breakout.
X All system componentshave been located.
X . The manholes were uncovered, opened, and the Interior was inspected for
for condition of material of construction; dimensions, depth of liquid, depth of
sludge, depth of scum.
N/A The size and location of the Soil Absorption System on the site has been
determined based on existing information or approximated by non-intrusive
methods.
X The facility owner(and occupants, if different from owner) were provided with
information on the proper maintenance of Sub-Surface Disposal System.
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 450 Mitchells Way,Hyannis
Owner: Ruth E. Williams Family Trust
Date of Inspection: June 25, 1997
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: 330 ;gallons
Number of bedrooms: 3
Number of current residents: 1
Garbage grinder(yes or no): NO
Laundry connected to system (yes or no):- NO
Seasonal use (yes or no): NO
Water meter readings, if available 94-95 21, 000
Last date occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharge to the Title 5 system:(yes or no)
Water meter readings, if available:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) YES
If yes, volume pumped: 500 gallons
Reason for pumping PART OF INSPECTION
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
2 Single cesspools
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection recods, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information.-
UNKNOWN
Sewage odors detected when,arriving at the site:(yes or no) YES
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 450 Mitchells Way
Owner: Ruth E. Williams Family Trust
Date of Inspection: June 25, 1997
SEPTIC TANK: N/A
(locate on site plan)
Depth below grade:
Material of construction: concrete metal FRP other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge 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 bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of:inlet and outlet tees ;or baffles, depth of liquid level in
relation to outlet invert, structural integrity, evidence of leakage, etc.)
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
Material of construciton: concrete metal FRP 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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation
to outlet invert, structural integrity, evidence of leakage, etc.)
6
°
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 450 Mitchells Way,;Hyannis
Owner: Ruth E: Williams Family Trust
Date of Inspection: June 25, 1997 h ;
TIGHT OR HOLDING TANK: N/A '
(locate on site plan)
Depth below grade:
Material of construciton: concrete " metal FRP other(explain
Dimensions:
Capacity: gallons
Design flow: gallons/day -
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: N/A_ j
(locate on site plan)
Depth of liquid'level above outlet Invert: `
Comments: F
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of
box, etc.)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(yes or no)
(note condition of pump chamber condition of pumps andwappurtenances, etc.)
y
L
t. .
7 4
LL
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 450 Mitchells Way, Hyannis
Owner: Ruth E. Williams Family Trust
Date of Inspection: June 25, 1997
SOIL ABSORPTION SYSTEM (SAS): N/A F.
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive
methods)
If not determined to be present, explain:
Type:
leaching pits; number:
leaching chambers, number:
leaching galleys, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
CESSPOOLS: X
(locate on site plan) FRONT REAR
Number and configuration: 1 1
Depth-top of liquid to inlet invert: 4 OVER
Depth of solids layer: 8" 4"
Depth of scum layer: 4" 1"
Dimensions of cesspool: 5' 5'
Materials of construction: BLOCK BLOCK
Indication of groundwater: NO NO
Inflow cessool must be pumped as part of inspection)
FRONT POOL& COVER 2' REAR POOL COVER AT GRADE NO
BELOW GRADE NO IN TEE NO O IN TEE, NO OUTLET POOL OVER-
OUTLET FLOWING REAR POOL OFF LOT
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc)
PRIVY: N/A
(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.)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 450 Mitchells Way, Hyannis
Owner: Ruth E.Williams Family Trust
Date of Inspection: June 25, 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR
BENCHMARKS
LOCATE ALL WELLS WITHIN 100'
3�
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation:
9
PERMIT NUMBER DATE
COMPLETED BY
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: 450 Mitchells Way Hyannis Lot No.
Owner: Ruth E. Williams Family Trust Address:
Contractor: Address:
Notes:
STEP 1 Measure depth to water table
tonearest 1/10 ft. ....................................:......................................... Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OA Appropriate index well....................................................
OB Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
month/year
STEP 4 Using Table of Water level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 28)
determine water-level adjustment ..........................................................................................
STEP 5 . 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 comutation form.
M
10
TOWN OF BARNSTABLE _�771V S)O A)
LOCUTION "�` l Em?-C // 1
1.� Gc�� r A � SEWAGE#
VILLAGE AIV ASSESSOR'S MAP Cz LOT a7*5F1''J13
r
INSTALLER'S NAME Sk PHONE NO. A & B CANCO 775-6264
N.'r- o®l
_OP5P7 C— NK CAPACITY S'a D �Q
LEACHING PACILITY:(type) CESS'/Joa (size)
NO.OF BEDROOMS PRIVATE WELL OIL PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No