Loading...
HomeMy WebLinkAbout0215 MAIN STREET (COTUIT) - Health �215 MAIN STREET, COTUIT A=023-001 i i } Commonwealth of.Massachusetts aa3 -av� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Main st Property Address Frances Frazier ' Owner Owner's Name Jwd information is required for every Cotuit Ma 02635 6/8/17 page. City/Town _ State -Zip Code. Date of Inspection ----- — Inspection results must be submitted on this form. Inspection forms may not be tered in any way. Please see completeness checklist at the end of the form. Important:When ti A. General Information C / filling out forms p ! c;?� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain ,y Company Name 8 Johns path Company Address R S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522. Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority .� , 6/13/17 l6pector'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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 o� VS i Commonwealth of Ma* ssachusefts �. W Title 5 Official [nspelCtion orrr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Main st _. Property Address Frances Frazier Owner Owner's Name information is Cotuit Ma 02635 6/8/17 required for 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. f Comments: System contains a 1,500 Gallon septic tank as well as a concrete distribution box and 4 infultrators. System is functioning as designed. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ec _ °M .215 Main st Property Address Frances Frazier. Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusettsf . W Title 5 Official inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e _ .. ��M 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma; 02635 6/8/17 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 t and environment : ❑. The system has a septic tank and soil absorption system SAS and the SAS is i P within Y 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 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 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 '/2 day flow t5ins•3/13 Title 5.Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Matsachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 page. City/Town State Zip Code Date of.Inspection B. Certif cation (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- 10,000gpd. ❑ ® 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 r 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 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/6/17 page. Cityfrown 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? ® ❑ 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? Z ❑ 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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I ' \ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ® No Water meter readings, if available last 2 ears usage d 218 GPD 9 ( Y 9 (gP ))� Detail:. r I Sump pump? ❑ Yes ® No Last date of occupancy: 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• /3 3 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I ' Commanvvea[th of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 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: July 2015 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 DEPyapproval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 s s Commonwealth of Massachusetts W Title 5 official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Main st M Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 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: 10/8/97 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grader 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 .If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17. a ; Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 215 Main st Property Address Frances Frazier - Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pace 10 of 17 Commonwealth of Massachusetts ° W Title 5 Official inspection Four, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth at Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Main st - Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 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 Level and at normal level 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.): 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.): I * II If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 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 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: „- ® leaching galleries number: 4 Infultrators ❑ 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.): No signs of failure 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•3/13 - - - - 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 215 Main st Property Address. Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635' 6/8/17 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotult Ma 02635 '6/8/17 page: City/Town -State Zip Code Date of Inspection D. System Information (cont.) 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Co mmonwealth of Massachusetts W Title 5 Official Ins eeti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 215 Main st Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/17 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: 12+ 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: 10/8/97 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i e _ e t r d . 2 y l o a � R r - nr� - TOWN OF BARNSTABLE LOCATION /�l"C�/1� %v . SEWAGE# VILLAGE ASSESSOR'S MAP &LOT 0043'— OWI INSTALLER'S NAME&PHONE NO. (�tJJ�:�I�Z�?, `f SEPTIC TANK CAPACITY !f o D LEACHING FACILITY: (type)/�u�,(!%{.k�r.4F( ��} (size) _Z0 x 3e, ` 4_Q NO.OF BEDROOMS BUILDER.OR WNE PERMITDATE: '� - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility - Feet Private Water.Supply-Welland.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 1 within 3W feet of leaching facility) Feet Furnished by 1 . R s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form Not for Voluntary Assessments 215 Main st 4 M Property Address Frances Frazier Owner Owner's Name information is required for every Cotuit Ma 02635 6/8/.17 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i COMMONWEALTH OF MASS ACHUSETTS 6 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: f. .C> Owner's Name:c /L /di fir,, d,yCt �t c'•`, Owner's Address: " Date of Inspection: 0 Name of Inspect. pleas print �� fft �® f o Company Names i ZEE P �� Mailing Address• Telephone Number:6®e_17?I Sac 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a'DE.P approved system inspector pursuant,to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils 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 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,,ystem owner and copies sent to the buyer, if applicable,and the approving authority. ;. Notes and Comments .. , �s IDS ..r .. -s�..•. ... ... .. A. ,.a».., ., . �,✓,...,. .�. a...`+.. .. is r ". � cat ****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 1 ii f: i . Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continyi;ed) Property Address:( A c, eZV— , A-1 Owner: � r� Pr�� i 22,aJ.,/ Date.df Inspection: _oA? ir''�r- G-- 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 cr_iteria.not evaluated are indicated below. Comments: 4,. B. System Conditionally Passes: One or more:system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair;as approved by the Board of Health,Will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements..If"not determined'.'please explain. The septic tank is metal and.over 20.years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltratioti or.tank failure is i aminent: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 le4king and if a Certificate of Compliance .indicating that the tank is less than 20 years old is available. ND explain: Observation-of sewage backup or break out or high 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping.more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of 1 l OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM`INSPECTION FORM PART A CERTIFICATION (continued) Property Address: IQ,Q i Owner: U piV Date of Inspection: aw- 7,2.d l 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.30 feet of a bordering vegetated wetland or a salt marsh 2. S stem will fail unless the Boa',d of Health and Public Water Supplier, if an deter y ( pp y) mines 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 I of a public water supply. The system has aseptic 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 DEEP certified laboratory, for coliferm 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: y i? ;P l 3 Y Page 4 of I 1 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION,(continued) Property Address: NE,&Xz k Owner: Date of Inspection: (,�,fit* 05 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 — --V/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool I Liquid depth in cesspool is less-than 6"below invert or available volume is less than day Mow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / Of times pumped V 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 cr privy is.within a Zone 1 of a.public well. Any portion of a cesspool cr privy is within 5.0 feet of a.private water supply well.. Any portion of a cesspool cr 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 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 necessaryto 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. 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 suppf� 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 I1 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. Paoe 5 of I I i,. OFFICIAL INSPECTIO'1 FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM? INSPECTION FORM PART B CHECKLIST Property Address:.;:1?J.e5_1 Owner: o Date of Inspection: _ l ..o Lr Check if the following have been done. You must indicate"yes"or"no"as to each of the followina: Yes No Pumping,information was prbvided 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 reLently'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? Were all system component, excluding the SAS, located on site _ Kfthe Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition fth baffles or tees, material of constPiction,dimensions, depth of liquid,depth of sludge and depth of scum Was the facility owner(and,occupants if different from owner)provided.with information on the proper maintenance of subsurface sewage disp0sal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes o i"Existing information.For example,a plan at the Board of Health. -Determined it the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15302(3)(b)]' t 5 Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATI"N w: Property Address: Owner: _ Date of Inspection: " —06 FLOW CONDITIONS RESIDENTIAL t,-' Number of bedrooms(.design):—3 Number of bedrooms(actual): DESIGN flow based.on 310 CUR 15.203 (for example: 11.0 gpd x#of bedrooms): a Number of current residents:Does residence:have a garbage grinder(yes or no): NO/ Is laundry on a separate sewage system,(yet or no);,/.[if yes separate inspection.required] Laundry system inspected(yes or no): 16 f 7 (��� Seasonal use: (yes or no): � 0 3 Water meter readings, if av ilable(last 2 years usage(gpd)): a�j'/ ,Do® Sump pump.(yes or no): 0 Last date of occupancy: COMMERCIAL/INDUSTRIAIWU Type.of establi slim ent: Design flow(based on 310 CMR 15.2C3): gpd Basis of design flow(seats/persons%sgf,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 r Pumping Records Source of information: 91j?UVd ('qnv Wass stem pumped as art of the i s -zction es or no): , Y P P P P- (Yr If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,.distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if yes, attach previous inspection records; if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance.contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval , _Other(describe): l Approxima a age o 11 co po ents,date installed(ifjknown)and source of information`. Were sewage odors.detected when arriving at the site(yes or no): 6 f : Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS�EM INFORMATION(continued) Property Address: 0/ ;J Owner: �1�l�0�1 Date of Inspection: BUILDING SEWER(locate on site plai)��/�. s Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: f/ (locate on site plan) _ It Depth below grade:,� Material of construction: concrete ;`metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate) Dimensions: /6Q5 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:�' Distance from top of scum to top of outlet tee of baffle: Distance from bottom of scum to bottom,of outlet tee or baffle: Iq How were dimensions determined: Comments(on pumping recommen ations, i et and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc) GREASE TRAP (locate on site plan.;) Depth below grade:_ Material of construction:—concrete_finetal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.); 7 i Page 8 of I 1 OFFICIAL.INSPECTION FORM—NOT FOR Y0:LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C pSYSTEM INFORMATION(continued) Property Address: r., C T Date of Inspection: < ` TIGHT or HOLDING TANKr/—Qk—(tank must be pumped at time of I nspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal fiberglass.___polyethylene - other(explain):. Dimensions.` Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working older(yes or no): Date of.lastpumping: Comments(condition of alann and float switches, etc.): a DISTRIBUTION BOX: f present must be opened)(locate on site plan) Depth of liquidlevel above outlet invert � r��t�etleu'al,&anyaevj(,,'4,enceComments(note if box is level and distribution t of solids carryover, any evidence of age into or our of box,ete �r PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no): Alarms in working order(.yes or no): 'Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): } u ' f Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY. ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_4_Z(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: chin' chambers,number: leaching galleries, number: leaching trenches, number, length:: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etch: ' _ G Ce s4l� ' CESSPOOLS: (cesspool must be ipumped 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:/A- 6 (locate on site plan) Materials of construction: Dimensions: Depth of,solids: Comments(note condition of soil,signs'tof hydraulic failure, level of ponding,condition of vegetation,etc.):. 9 Page 10 of 1 I OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY_ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM FART C SYSTEM INFORMATIOMI(continued) Property Address: 10/5 d 2,N Owner: ' ;1 Date of Inspection: ,g9�t �` 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. 1 Y t f t i o . ' fffQQQ �J i 5Do cQ,flo�n � �(ki - . 3�-s -fin mps r in Page 1 I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,- &J- Owner: Date of Inspection: ? ;a'Poor SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Meet 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/o�lservation hole within 150 feet of SAS) Checked with local Board of Heald)-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: t II Permit Number: Date: -Y... x Completed by: �( HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Z/: 1 ��, �`�/ ( f,� Lot No. Owner: f(yJ��°j� /G'r�'����++ !^ Address: Contractor: xzql Cv/• Address: f�J— v�'ej. Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ..................................... . .Date ............:............................ month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: p OAppropriate index well:............................................. OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to DS,/ .sal 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 2B) ✓'' 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) ........................................................................ i - Figure 13.--Reproducible computation form. 115 �. _...... •........... .:. =�..,�.�.� --- ._..�....._.��._...�._._..� .._......_ h; _.a�:;,I, ........... I 5 r' TOWN OF BARNSTABLE y'`UCATION�i� Qt/7 ��-re SEWAGE #G 7. SCaQ ,' .LAGE ASN OR'S MAP & LOT(`Q 00 5P8 °7o `5 NAME&PHONE NO ) C'�% g T7 �_R SEPTIC TANK CAPACITY � fl LEACHING FACILITY: (type) T a reA lamV� (size) )U°Le)l; —:36' NO. OF BEDROOMS BUILDER Ol d�1r.i.S Y R,�r—L f PERMTTDATE: 0 C° �' ° C)7 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6 / � � 3 O � " Olt 1rul � s i TOWN OF BARNSTABLE �' �� gg c /b LOB ATION l Ala/tl S7- 49 SEWAGE # VII.i. iGE ce taI r ASSESSOR'S MAP & LOT®L3—O®/ INSTALLER'S NAME&PHONE NO.. SEPTIC TANK CAPACITY i,S`d D Aa G LEACHING FACILITY: (type) f�-s�J6,LtH��ce�5 �7�— (size) /0'X30' z Z/ NO.OF BEDROOMS BUILDER OR R � er PERMTTDATE: 'r, COMPLIANCE DATE: 16 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility . 3_)�' 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 �sr� 33 �y. . OO No. —I-" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplicatton for Mizpoodf 6p.5tem Cow5truction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) [ Complete System ❑Individual Components Location Address or Lot No. ° G Owner's Name,Address and Tel.No. Assessor's Map/Parcel Go�'��/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. BD/��71`C1 Cd��r` 7? -9�99 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(140 Other Type of Building wn_,_, No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �® gallons per day. Calculated daily flow a a?� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. A,-9 Description of Soil Nature of Repairs or Alterations(Answer when applicable) �— Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t is B of O / Signed Date �4 l c� Application Approved by Date /O ,f Application Disapproved for the lowing reasons Permit No. 7 — 7J Date Issued - No: Fee y - - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � �^ _ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS awlication for Miopogar *proem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) LJ Complete System ❑Individual Components Location Address or Lot No. Z Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. BO/f�Lo1�i Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. GarbavGrinder GA Blew Other Type of Building S% No. of Persons„- Showers( ) Cafeteria( ) Other Fixtures Design Flow f /0 �' �" r ' 'gallons per day. Calculated daily flow ✓C gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank f SDC� / -'------Type of S.A.S. /O X 3DX z Description of Soil i Nature of Repairs or Alterations(Answer when applicable) ` r Date last inspected: Agreement: i 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 t is B of Ida ----------- Signed d � �� �� Date �Z::: i Application Approved by Date /4 7 Application Disapproved for the o lowing reasons Permit No. 7 — rJ�� Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 073 -'©d/ BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE IFY,that t e O�n}- ite Sewage Disposal System Constructed( )Repaired( )Upgraded( Abandoned )byDl�`� O/T at �/.S /�1 5� d/ Gl� / has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - s dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date i r) �o - Inspector- --------------------------------------- / No. ` t/ (7 / (/ Z.3; dv/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwi!6pogal *p5tem Construction Permit Permission is hereby anted to Construct( )Repair( )U grade(V)Abandon( ) System located at �S 17lG, //? ,y T. d 7`4"/ 7- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: / 0 7 Approved by �� Z NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH kND APPLIC aTION FOR A DISPOSAL WORKS CONSTRUCTION PERINUT (`WITHOUT DESIGNED PL NS) i�.ebv arri:caiicn _'0^S rdClic nelmi :a_nez =` e da-Led :_`"�i 'rc 77i _ Cared 3r --rZna: 7.0 � __��_ -•--- ^;'i; --- - _ Z Z7 7:C LICENSED SEPTIC SYSTEM.NSTALLER iN_.E TOWN OF BARNSTABLE NFUNMER [Attach a sketch plan of the proposed system.Also if to licensed installer posesses a certified plot pian. this plan should be submitted]. Irk, 12 •t'. i 4 q:hatch tolde� ,•_ 1 v. Vip CIA 00 III � L 0,4_L/�P V Q t TOWN 04 BARNSTABLE LOCATION SEWAGE # 7 SS6 VILLAGECd7�L1r� ASSESSOR'S MAP & LOT�L3—OO� INSTALLER'S NAME&PHONE NO. X01 Zel-0 GDe,S7` — SEPTIC TANK CAPACITY (type) _ LEACHING FACII.TTY: (size)/a".410 ' xot NO.OF BEDROOM BUILDER OR R �.— " ERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ✓rf Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) g Feet Edge:of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �.F�eet Furnished by r 00 i o/j ,� ; E t.� � .i, �. +. � --ram r7 �� � � � � i s ' � � � �♦ �� .a._ � • 1 a �i �� ,Y ,� ` ,� � w �/ � � f _� _ ,y �N� r 1f}� � (� ff � i /-_ �,. .� �� �� �� ��-�,.� , __ _ -- _ � _