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HomeMy WebLinkAbout0171 PITCHER'S WAY - Health 171 PITCHERS WY HYANNIS A = 289 018 e 1 i f S o Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms ,u ✓ on J'I 4 �j/�j�j computer,use 1. . Inspector: /✓ only the tab key to move your 'Robert Paolihi cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 673 Company Address Centerville Ma. 02632 xenon City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification 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 ❑ Tails `=y ❑ Needs Further Evaluation by the Local Approving Authority =. JlCIO 7/01/2009 l r Inspector's S fiatW Date ir * 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. ****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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of if.' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pitcher's Way Property Address -Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please 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. ❑ Y ❑ N ❑ ND (Explain below):. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r) f: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �nM 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 171 Pitcher's Way _ Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more'than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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 1 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design,flow of 2000gpd- 1 0,000g pd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone 11 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. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate "yes"or"no".as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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 back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is Hyannis Ma. 02601 7/01/2009 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon septic tank,distribution box and two drywells. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: 7/01/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for H annis Ma. 02601 7/01/2009 y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes '® No Building Sewer(locate on site plan): ' Depth below grade: 16"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from privatew ter supplywell or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallon Sludge depth: 3,. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" 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.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for H annis Ma. 02601 7/01/2009 y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms In working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 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, etc.): Sandy dry soil.No signs of hydraulic failure.Drywells were dry at time of inspection with stain line 14" below invert. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration . Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel'Viewer Custom Map Abutters Map Size Zoom Out ,In A K and :a , i 1 rl )' 1 1 1 1 t� 1 / 1 ,. ® ! y y:. `C {� VI t � , F r t / 1 AS t 1 1 Fr i ,, S4 , S 2-0 Fee t ............ Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER r:nnvrinhf,)nnr-,)nn0 T—urn of Rarnefahla KAA All rinhfc recant, httn'Hwww.town.harnctahlP.ma,ttc/arrimc/annoPnann/man acnv9nrnnP.rtvTn=)ROO1 RRrmann 7/1/,)nno Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is Hyannis Ma. 02601 7/01/2009 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LC 22' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 - 4S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pitcher's Way Property Address Peter Skentzos Owner Owner's Name information is required for Hyannis Ma. 02601 7/01/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file z t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS kq Jr. DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 171 Pitchers Way Hyannis Owner'sName: Ellen Johnson 0� Owner's Address: - 171 P►+ckta aY Date of Inspection: Name of Inspector:(please print),, Sean Jones Company Name: William E R—Robins,,,—oepuj:c—service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: _(5081 77 -8776 CERTIFICATION STATEMENT 1 certify that 1 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 ction 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs F va tion by the Local Approving Authority Fails Inspector's Signature: Date: w 3 nook The system inspector shall submit a copy of this inspec io report to the Approving Authority(Board of Heanhvr,. 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 ha p y s Il submit the report to the appropnate 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 ""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 I Page 2 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1.71 Pitchers Way Hyannis Owner: Ellen Johnson Date or inspection: f v 3 aooro Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. em Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMP, 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: tsar_-3,47, 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 strucWrall unsound e Y exhibits substantial infiltration or exfiltrahon 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: r Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipes)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 obn cted pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is r ==d ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION(continued) Property Address: 171 Pitchers Way Hyannis Owner: Ellen Johnson Date of Inspection: . jj7 00 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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 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 frond 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: 3 Page 4 or l l OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION(continued) Property Address: 171 Pitchers Way Hyannis Owner: Ellen Johnson Date of Inspection: /o%1,9606 D. System Failure Criteria applicable to all systems: You must indicate'yes".or"no"to each of the following for all inspections: Yes Np _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ DischarBe or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ` clogged'SAS or cesspool J Static liquid level in the distribution box above.outlet,invert due to an overloaded or clogged SAS or j cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less'than'/2 day-flow Required pumping more titan 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ f Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 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 Kater 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 15.303,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 ..N . To be considered a large system the system must serve a fac0ity with a design-(low of i opo 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 systcmi 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 I 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 "ycs"in Section D above the large system has failed.The u%mcr ar 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 171 Pitchers Way Hyannis Owner: Ellen Johnson Date of Inspection: /a/34 ao 6 Check if the following have been done.You must indicate`)es"or"no"as to each of the following: Yes N� _ ZWere Pumping information was provided by the owner,occupant,or Board of Health any of the system components pumped out in the previous two weeks? v _ as the system received normal flows in'the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) V Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank:manholes uncovered,opened,and the interior of the tank inspected for the condition of thh bafpes or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? y _ 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 an of the failure criteria related to Part C i a 'Y s t Issue approximation of distance is unacceptable)[310 CIv1R 15.302(3)(b)) 5 Page 6 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 171 Pitchers Way Hyannis Owner: Ellen Johnson Date of Inspection: O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): 3,30 6 P D Number of current residents: I Does residence have a garbage grinder(yes or no):pia Is laundry on a separate sewage system(yes or no):L4D [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water0 4/0 5 - 36,750 meter readings,if available(last 2 years usage(bpd)).. Sump pump(yes or no):_L�? - , 0 0 Last date of occupancy: Cv rrc,.,1- COMMERCIAIANDUSTRIAL r/, Type of establishment: Design now(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: Was system pumped as part of the inspection(yes or no):_NLa 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) _Tigbt tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: /V0, SySfcn. 19gq Were sewage odors detected when arriving at the site(yes or no): 6Lp 6 I'agc 7 of I I OFFICIAL INSPECTION 10I01 -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPTCTION F01111 PART C SYSTEM 1NFOR IA'TION (continued) Proptrty Address: 171 Pitchers Way _Hyannis Owner: Ellen Johnson Dale of Inspecllon: BUILDING SLIvE11(locale un silt plan) Depdi below grade: ('6 Maletials of construction:_cast iron st/4U PVC_other(explain). Distance from private walct supply%sell or suction live:_ Comments(Oil condition of juutts,venting,evidence of Icakagc,cic.): SEPTIC TANK:✓(lucatc on site plan) Depth below grade: a Material of eonstruUion: V cunctctc metal fiberglass�iul�cUrylcne uthct(explain) —' —' If sank is metal list age:_ Is age cunfirmed-by a Cettiftcale u(Cunn tliance es or nu cctlificatc) l O' ) _(attach a cup)-of Dimensions: I tmb ,,,,s Sludge dcplh: (o'` Distance front Ivp of sludge to bonum of outlet ice or bafllc: 36 Sewn lhiekness: )" Dislancc from 101)of scum to Ivp of outlet ice or bafllc: Distance from butivnt of scum to bottom of uutict Ice or bafllc: 73" Ilow»ctc dimensions determined: C>PeAcd Guyer• e,.) }flame ►Meu5,rer�e,t-4 Comments(oilpumping reconunetJatioms,inlet and outlet tee or bafllc condition, sltuctutal inte6rit)-.liquid Ic%-cis as rclalcd to outlet utvctt,evidence of leakage,c1c.): � ,5 ]crwLC rn cS SM.c><1ta� -0,, �( a} (L'a[�c rw— GREASE TRAP: N((locale on site plan) Dcplh below grade:_ Material of construction:__cunucle metal libuglass`pul)•cilt)•Icnc _outer (explain): — Dintatsions: Scum Ihickrtcss: Dislancc Gotsi top of scum to Ivp of outlet Ice or.bafllc:_ Distinct Gom button,of`scunt to bunvm of outlet Icc or bafllc: Dale of last pumping: Cununcnts(on pumping Iccununcndalium, inlet and outlet Ice of bafllc(undilio:1,sltuc till al inlcplly,liquid IcvC13 as rclalcd to oullcl imcil,evidence of Icakagc,etc.). 7 1'agc 8 of I't OFFICIAL INSPECTION FORM _N07'I,OIt VOLUNTARY ASSLSSMMYS SUUSUIWACL SENVACE DISPOSAL SYSTEM INSPEIC'1•ION FORM PART C SYSTUI INFORMATION(cunlinucd) Properly Address: 171 Pitchers Way _Hyannis Owner. F1 1 p Johnson Date of lospeclloo: b TIGHT or HOLDING TANK.41"Xtartk must be pumped at lime of illspeclioll)(lucate fill site Man) Depth below grade: Malelial of construction:__concrele_ttlelal_fiberglass_jwlyelliylene_olher(explain): Dimensions: Capacity: ralluns Ucsign flow, galluns/da)• Alarm prescnt(),cs fir no): Alarm level: Alarm in wutkin urdcr Date of last pumping; 6 [Jcs or mu): Cununents(condition of alarm and lluat swirclies,etc.): DISTRIBUTION BOX:✓(if prescnt must be opcncd)(locatc on silc plan) Dcpth of liquid level above outlet invert: Conuncnls(note if box is level and distribution to outicls equal,any cvidcnce of solids ca,r)•over,any evidence of leakage into or out of box,cic.): �Is aS 'LI.G q...o,( INOJc' Cc.iGI f r7dw CCP %n✓er - PUAII'Cl1AA1UEll: A/l' on locate ( sue plan) . Pumps in working order(ycs or no):_ Alarms in ss•orking order(ycs or no): Conuncnls -- nutc c( onJ" tUon of pump chamber,condition of pumps and aly)uttenan(es,uc.): . . Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . 171 Pitchers Way Hyannis Owner: Ellen Johnson Date of Inspection: to o+o SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:y/ _ leaching chambers,number: o� leaching galleries,number: { leaching trenches,number,length: - leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic.failure,level of ponding,damp soil,condition of vegetation, etc.): 5" �.-4� cl ¢I e+-,-fij— L. Q. s r.,,a(� , o;4- 47 GG �/lSAec-ki t°eLC� G-�a., b41S �n� lGSS 1 tn+GG. �r w ov. Q15 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: N I (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 1 l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 171 Pitchers Way Hyannis Owner: Ellen Johnw Date of Inspection: 1 b rho a� 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. ���11E Sr,Q-e DG �oJS� Of O O a lJ a 3 TNN V� A-t 1�-aaT A 37' Sas A-3 a� ` Q-3= a's' 10 Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 171 Pitchers Way Hyannis Owner. Ellen Johnson Date:of Inspection: l c5 3 2 c--;,6 SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 6 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: Observed site(abutting property/observation hole within I50 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: C—ouxJ _c_ cr -let/c:-f-7d. J L -4s r t4.tr ,ti 1 QCCCss r ice,...,.. c)r 6Erit �y�4 Gnu. {cr Co✓4b 11 dl- 11 f TOWN OF BARNSTABLE Bill LOCATION. 01 !?t` "&12S [AiX$L SEWAGE# 1 L a 6 ' VILLAGE Nmi-i'v 5 ASSESSOR'S MAP &LOT lJ INSTALLER'S NAME&PHONE NO. {_xJ9`1 f&h;A)5QtJ Sf-pfk i `7 7 S 77 7C SEPTIC TANK CAPACITY 5co !' LEACHING FACILITY: (type) ;. "Die k f S (size) a S f a-A l j NO.OF BEDROOMS '3 ' BUILDER OR OWNER PERMTTDATE: S' f 3 5 5 ' COMPLIANCE-DATE: S l9 . t 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 � 1 e far ® i :qT � Fee$50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes"'' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprirattorl for Mtgogal *p5tem Construction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) []Complete System ❑Individual Components LQc�iQnPdd1 chers Way, Hyannis , MA Georgee'Johnsonl.No. Asllsessoor's1i''Map/Parcel 7 7 5-5 7 3 6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville , MA Type of Building: Dwelling No.of Bedrooms 1 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 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable) N P w T i t 1 e— 2 r)t i e i n n _ tank, n—box and 2 leach chambers . 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 this B and of HeaAh. Signed IM A 41 a Date. '" 3 Application Approved by Date Application Disapproved for the following reason Permit No. � Date Issued �� r { �. � t �; k i e 'r T R' i� ' _ f 3 i t r I " F .. x _� ,�. . :�� �f' ,t i R J �" r t i $50 No. O Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSET-'TSI-T 5 01ppYication for Migogal *pgtem Construction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Y Lqc iqnAd dr s Lot No. y Hyannis, j� 8wner's Name,Address and Tel.No. f rlet`c�lers Way, eorge o nson Assessor's Map/Parcel 77 5-57 3 6 Installer's Name,Add §s and TO.No. Designer's Name,Address and Tel.No. -Wm. E. Robinson Septic Service P 0 Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 3 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 gallons. Plan Date Number of sheets Revision Date Title Size of Septic"Tank ' Type of S.A.S. Description of Soil IS And. Nature of Repairs or Alterations(Answer wheflC pplicable�. New Title-5 septic inc , tank, D-box and. 2 leach chambers . NXo 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 th' B and of Hea . Signed 8 Date S 13 4 Application Approved by Date Application Disapproved for the following reasons 4" Permit No. U V*or Date Issued —`——————————— -------------------------- THE COMMONWEALTH OF MASSACHUSETTS Johnson BARNSTABLE, MASSACHUSETTS Certificate of Compliance `� THIS IS TO C7TIFY�thaWhebOn-,s ` �D' Cos Shy et�toCeonstructed( )Repaired (X )Upgraded(' ) Abandoned( )by at 171 Pitchers Way, Hyannis, MA constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.q q::� dated Installer Wm. E . Robinson Sr., Designer n n Ct? Al The issuance of this peryiit sh : 1b co stctTd`as a guarantee that the syst rtl fu cti a de'' med. !( ' Date GV Inspector�'f /. � 'v M --- ————————————————————————— ..No. � Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Johnson PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS �Dtzpogar 6pgtem Con5truction Permit Permission is hereby granted to Construct( .)Repair(X )Upgrade( )Abandon( ) System located at 71 Pithchers Way, Hyannis, MV 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: Construc on ompleted within three years of the date of this e it.Date: Approved by � % if 1 040ffi4ii� 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) I, William E. Robinson,Sr. ,hereby certify that the application for disposal works construction permit signed by me dated S-1 'Z/ concerning the property located at 171 Pitchers Way,Hyannis, MA meets all of the following criteria: * There are no wetlands 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 with 250 feet of any 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 Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: 4�0 i� / DATE l3— LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). i I I i i i - i E i j, I i r i f � o I � '� Ell ®© TOWN OF BARNSTABLE LOCATION 171 R1 SEWAGE # VII LAGE Ny,ga�,�5 ASSESSOR'S MAP& LOT_ INSTALLER'S NAME&PHONE NO.udk t Rn�i` SUN S nfi�' 7 �7 7l SEPTIC TANK CAPACITY 6 SCE LEACHING FACILITY: (type) y_ s.a (size) a S f 1 X l NO.OF BEDROOMS 3 BUILDER OR OWNER . PERMTTDATE:_Y,/<-4./5 9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply W pp y 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 v`? Qt 1