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HomeMy WebLinkAbout0216 SEVENTH AVENUE (HYANNIS) - Health 216 SEVENTH AVENUE HYANNIS A= 245 - 081 '1 t usetts Commonwealth of Massach �S Title 5 Official Inspection Form COPSubsurface Sewage Disposal System Form-Not for Voluntary Assessments � 4 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28, 2020 required for 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:When A. Inspector Information filling out forms on the computer,use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Company Address V1&A Forestdale MA 02644 City/Town State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2: Conditionally Passes 3. 0 Needs Further Evaluation by the Local Approving Authority 4. 0 Fails July 29 2020 Inspector's Signature Date 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner owner's Name information is required for every West Hyannisport MA 02672 July 28, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2,3, or 5 and all of 4 and 6. 1) 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: 2) System Conditionally Passes: El 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 deter ined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 ars old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltra i n or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is re aced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass nspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that t e tank is less than 20 years old is available. Q Y O N 0 ND (Explain below): t5insp.doc-rev.726/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28, 2020 required for every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cunt.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Observation of sewage backup or eak out or high static water level in the distribution box due to broken or obstructed pipes)or ue to a broken, settled or uneven distribution box. System will pass inspection if(with approval f Board of Health): Y 0 broken pipe(s)are re aced Y N ND(Explain below): obstruction is rem ed �� © Y N ND(Explain below): 8 distribution bo s leveled or replaced ©-Y N 8 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): El broken pipe(s) are replaced 1 0 Y N ND (Explain below): obstruction is removed f% � Y N 8 ND(Explain below): 3) Further Evaluation is RetBoard ard of Health: Conditions exist whicvaluation by the Board of Health in order to determine if the system is failing talth, safety or the environment. a. System will pa 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: t5insp-doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is required for every West Hyannisport MA 02672 July 28, 2020 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 0 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 b. 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 sorption system (SAS)and the SAS is within 100 feet of a surface water supply or trib ry to a surface water supply. Ll The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. 8 The system has a septic tank an SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank nd SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply ell**. Method used to determine dista ce: **This system passes if the well ater analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates abse t and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provide that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 LN� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West H annis ort MA 02672 July 28, 2020 required for every y p page. Cityfrown State Zip Code Date of Inspedion C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No 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 '/2 day flow 8 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 water supply well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 8 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 2000 gpd- 10,000 gpd. 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. 5) 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 CA. Yes ,. No 0 the syst/wiin feet of a surface drinking water supply 8 the syst feet of a tributary to a surface drinking water supply the systa nitrogen sensitive area(Interim Wellhead Protection Area—Ied Zone II of a public water supply well t5insp.doc•rev.7/26l2018 Offic al Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments — 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is required for every West Hyannisport MA 02672 July 28, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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? Were as built plans of the system obtained and examined? (if they were not available note as N/A) © Was the facility or dwelling inspected for signs of sewage back up? �] Was the site inspected for signs of break out? 0 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 tilo facility owner(and occupants if different from ownw) pr@Vid@d 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: F 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)] I t5insp.doc•rev.7/26/2018 Ti to 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow b@s@d on 310 QMR 15.203 (for examplo 110 gpd x#of 0edroem§)° 331 GPD Description: 4 Number of current residents: Does residence have a garbage grinder? 8 Yes 0 No Does residence have a water treatment unit? Yes 8 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) Laundry system inspected? Yes No Seasonal use? Yes No 2018=258 GPD* Water meter readings, if available(last 2 years usage (gpd)): 2019=296 GPD* Detail: *High water usage diring summer months due to irrigation. Sump pump? Yes No Current Last date of occupancy: Date t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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? 0 Yes 0 No Water treatment unit present? 0 Yes [ No If yes, discharges to: Industrial waste holding tank present? 0 Yes No Non-sanitary waste discharged to t Title 5 system? Yes 8 No Water meter readings, if availabl . Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owners records: Pumped Summer 2017 Was system pumped as part of the inspection? 8 Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system Single cesspool 0 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. 0 Other(describe): Approximate age of all components, date installed (if known)and source of information: System installed 08/13/2003 Certifiacte of compliance on file at Health Dept. Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer(locate on site plan): 28" Depth below grade: feet Material of construction: cast iron 2140 PVC other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis - Owner Owners Name information is West Hyannisport MA 02672 July 28, 2020 required for every State Zip Code Date of Inspection page. Cityfrown D. System Information (cont.) 6. Septic Tank(locate on site plan): 20" Depth below grade: feet Material of construction: concrete metal fiberglass 0 polyethylene 8 other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 8 Yes LD No 10.5'x 5.5'x 5' 1500 gallons Dimensions: 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 30" 8"at inlet Scum thickness 6„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Approx 12" Dip tube mirror and tape measure How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Outlet viewed with mirror and light. Outlet not accessabile. Under Trex deck. Inlet has access panel. Liquid level at outlet invert. Risers brings inlet cover to grade under pael. Owner to have tank purred within 30 days. Recommend maintenance pumping every two years with full time use. t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 216 Seventh Ave. + Property Address Christopher Gillis Owner Owners Name information is West Hyannisport MA 02672 July 28 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: F1 concrete metal — fiberglass polyethylene other(explain): Dimensions: Scum thickness Distance from top of scum to to of outlet tee or baffle Distance from bottom of scu to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping r commendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related t outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: 8 concrete 0 metal rl fiberglass 0 polyethylene other(explain): Dimensions: I Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 . t Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner owner's Name information is West Hyannisport MA 02672 July 28, 2020 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: Ej Yes No Alarm level: Alarm in working order: Yes No Date of last pumping: Date Comments(condition of alarm and flo switches, etc.)-. *Attach copy of current pumping contract(required). Is copy attached? Yes 8 No 9. Distribution Box(if present must be opened) (locate on site plan): 5„ Depth of liquid level above outlet invert 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.): One inlet, one outlet. Installed riser and 18"concrete cover to bring access just under pavers.Very light solids carryover. Liquid level .5 over outlet invert due to slight backpitch for first 3' of outlet line. No sign of high water staining over operating level H-20 DB-3 is 3' below grade. t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: 0 Yes 8 No* Alarms in working order: Yes 8 No* Comments (note condition of pump ch mber, condition of pumps and appurtenances, etc.): i * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: leaching chambers number: r leaching galleries number: 0 leaching trenches number, length: leaching fields number, dimensions: 448 sgft overflow cesspool number: innovative/alternative system Type/name of technology: t5insp.doc-rev.7262018 Title 5 office tnapection Forth:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. -' Property Address Christopher Gillis -- Owner Owner's Name information is West Hyannisport MA 02672 July 28 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Camera used to inspect leach field. No standing liquid at time of inspection. No staining over perferation holes No sign of past hydraulic failure. 12. 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 8 No Comments(note condition of soi, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs/ydraulicfailure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West H annis ort MA 02672 July 28, 2020 required for every y p page. City/Town State Zip Code Date of Inspection D. System Information(cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: hand-sketch in the area below drawing attached separately i i I \63 ` � t5insp.doc•rev.7r26r2018 Title 5 Official hspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner Owner's Name information is West Hyannisport MA 02672 July 28, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water �] Check cellar Shallow wells >5 Estimated depth to high ground water: 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. 2003Date M Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: maps massg is.state ma us/oliver.php You must describe how you established the high ground water elevation: Test hole in 2003 to 10'found no ground water. Base of field 5' below grade. Slope to water drops well below base of leach field. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Seventh Ave. Property Address Christopher Gillis Owner owner's Name information is required for every West Hy p annis ort y MA 02672 Jul 28, 2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included F t5insp.doo-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 k j V TOWN OF AARNSTABLE LOCATION � -1 VZ- AV+ C- SEWAGE # 00,3 VILLAGE A f— ASSESSOR'S MAP & LOT vt' YT �I INSTALLER'S NAME&PHONE NO: kA"C.t� 06am 1' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) S9 9 NO. OF BEDROOMS ( ° BUILDER O 'OWNER PERMITDATE: COMPLIANCE DATE:, Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �7� Feet Edge of Wetland and Leaching Facility (If any wetlands exist m,, within 300 feet of leaching aci ' ) ICE Feet Furnished by oq -, � � _., .- ��� � r �� — a� _ �� i --. ;�� �--_. . , �. 1J