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Home My WebLink About0336 LINCOLN ROAD - Health 336`L'incoln. Road Hyannis P A = 271 067 e I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF�ENVIRONMENTAL PROTECTION T TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM_FORM PART A RECEIVED CERTIFICATION Property Address: 336 Lincoln Rd`. DEC A 0 2002 Hyannis, MA 02601 TOWN OF BARNSTABLE Owner's Name: Jill Spinney HEALTH DEPT. Owner's Address: Same Date of Inspection: / -G ;---a imp 7 ` t � �� ... Name of Inspector:(please print) William E_ . Robinson Sr. PARCEL Company Name: William E. Robinson Septic Service COT 7 Mailing Address: P 0' Box` 1089 Centerville, `MA _ Telephone Number: (_508) 775-8776 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.12111 a DEP approved system inspector pursuant to S ion 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:4Z�c � X�1_ Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth'or DEP)within 30 days of completing this inspection.If the system is a shared system or bas 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. 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 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued): e Address: 336 Lincoln Rd- Hyannis.�y yannis. Owner: Spinney Date of inspection: Inspection Summary:;Check A,B,C,D or E/ALWAYS complete all of Section D Y 3 A. Sy em Passes: 1 have not found any information which indicates that any oft e failure ailur criteria de cribed in 310.CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria no Comments: B. "System Conditionally Passes: - One or more system components as described in the"Conditional Pass"section need d be replaced or reps ed:-The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. ND in the for the following statements.if"not determined"please determined Y N, ) , lexpla, r yes,no or not dete ( , tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurall on if the The septic inent.S tem will pass inspectiimmits substantial infiltration or exfiltration or tank failure rs ysd exhtbt s tic tank as roved b the Boardof Health: g tank is replaced with a complying ep approved y •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 a plain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or ted Ob obs cOb pipets)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND ell plain: The system required pumping more than 4 tines a year due to broken or obstructed p�(s) The system will pass ' spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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: 336 Lincoln Rd. Hyannis, MA 02601 Owner: Spinney Date of Inspection: C. urther Evaluation is Required by the Board of Health. onditions 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. Sy ter will pass unless Board of Health determines iri accordance with:310'CMR..15.303(1)(b),that the-, Sys in is not functioning in a manner which will protect public health,safety.and the environment: esspool or privy is within 50 feet of a surface water esspool or privy is within50.feet of a bordering vegetated wetland or a salt marsh,; - . 4R• > 2. Syste will fail unless the Board of Health(and Public Water Suppler,if any)determines.that:the system is unctioning in a manner that protects the public health,safety and environment: _ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfac water supply or tributary to'a surface water supply. e system has a septic tank'and SAS and the SAS is within a Zone I of a public water supply. he system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a priv to water-supply well••.Method used to determine distance '• his system passes if the well water analysis,performed at a DEP certified laboratory, for colifonn b teria and volatile organic compounds indicates that the well is free from pollution from that facility and: t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ailure criteria are triggered.A copy of the analysis must be attached to this form. 3. Ot er: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ST EM INSPECTION FORM SUBSURFACE SEWAGE DISPOSAL SYS _, ,,, PART A CERTIFICATION(continued) Property Address: 336 Lincoln•Rd. yannis, MA 0260 Owner: Spinney z Date of Inspection: y-71'- .... .. ... f' D. System Failure Criteria applicable to all systems: You mu t indicate'yes"or"no"to each of the following for all inspection s:Yes N . . _ Backup of sewage system component due to overloaded or d*clogged SAS cesspool into facility or 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 aboveoutlet invert due to an d r clogged SAS or overloaded o cesspool _ Liquid depth in cesspool is less than b".below invert or available volume is less than'/:day flow 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. t of a surface water supply or tributary to a surface Any portion of cesspool or privy is within 100 fee 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 wa=T 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 ihaf facility and the that rice of a failure criteria onia nitrogen and nitrate nitrogen is equal to_or less th%an 5 ppm,p . . „. „ . . are triggered.A copy of the analysis must be attached to this formal (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: 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 water su 1 e system is within 400 feet of a surface drinking PP y system is within 200 feet of a tributary.to a surface drinking water supply the ystem is located in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped Zon II of a public water supply well . ered If you have an eyed"yes"to any question in Section E the system a can a significant. at,d red a "yes"in Sectio D above the large system tras failed.The ovvn�or operator of any gsystem significant threa under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syst m oN%mer should contact the appropriate regional office of the Department. 4 Page 5 of 1 I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- CHECKLIST Property Address: 336 -Lincoln Rd. Hyannis, MA 02601 n Owner: Spinney Date of Inspection: 2,—X—�'�— Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No� _ �1_// Pumping information was provided by the owner,occupant,or Board of Health, v 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 intro duced 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? — r P g _.. 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 baffl s 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: Yes no/ . Existing information.For example,a plan at the Board of Health. E A_/ V_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 Page 6 of l 1 OFFICIAL INSPECTION FORM NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART..C SYSTEM INFORMATION Property Address: 336 Lincoln Rd. ... . Hysnnis, MA 02601 Owner: Spinney Date of Inspection: �-- FLOW CONDITIONS RESIDENTIAL i - Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . ,3 v Number of current residents: P.— Does residence have a garbage grinder(yes or no): a Is laundry on a separate sewage system(yes or no):,Z) [if yes separate inspection required] Laundry system inspected(yes or no):_ .o Seasonal use:(yes or no):Z1,V 01.— gal. Water meter readings,if available(last 2 years usage(gpd))"` 1: Sump pump(yes or no): v Last date of occupancy: =o ,... CO ERCIAL/INDUSTRIAL Type o establishment: Design flow(based on 310 CMR 15.203): °gpd Basis o design flow(seats/persons/sqft,etc.): Grease ap present(yes or no):_ Indus al waste holding tank present(yes or no):_ Non-s itary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last to of occupancy/use: " OTH R(describe): GENERAL INFORMATION Pumping Records Source of information: �g Was system pumped as padof the inspection(yes or no):/ O If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TL/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): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):A D 6 Page 7 of 11 OFFICIAL INSPECTION FORM NOTFOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART :. . . SYSTEM INFORMATION(continued) Property Address: 336 Lincoln Rd. Hyannis, 601 iAne Owner: S P ' ' y ..: ... ; Date of Inspection: /;PL_ —d'� BUILDING SE ER(locate'on site plan) Depth below de Materials of c nstruction _cast iron _'40 PVC•:_ other(explain): A Distance fro private water supply well or suction line: Comments on condition of joints,venting,evidence of leakage;etc.): SEPTIC TANK: cate on site plan) _ Depth below grade: _ Material of construction: concrete metal fiberglass_polyethylene _other(explain)- " If tank is metal list age: Is age confumed•by a Certificate of Compliance(yes or no):-(attach_a copy of " certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: A— Scum thickness::' --3 a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom outlet tee or baffle: How were dimensions determined: 0L✓L.. (tea L ,ti�2 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels. ' as related,to✓outlet invert,evidence of leakage,etc.): � z GREA E TRAP:_(locate on site plan) Depth b low grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain) Dimensi s: Scum thi ess: Distance .om top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comment (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related o outlet invert,evidence of leakage,etc.): 7 Page 8 of l l 4EN OFFICIAL INSPECTION FQRM NOT FOR VOLUNTARY TN F TTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN:SPE PART C ,. SYSTEM-INFORMATION(continued) 336 Lincoln Rd. Property Address: yanni s, 6 01 Owner: spinney Date of Inspection: TIGHT or H DING TANK: _(�must be pumped at time of inspection)(locate on site PIP), Depth below gra e: — fiber lass olyethylene other(explaut): , Material of cons ction: concrete metal g —p, J Dimensions: - Capacity: _gallons ' allons/day Design Flow: Alarm present(ye or no): Alarm level: Alarm in working order(yes or no): Date of last pum ing: Comments(con ition of alarm and float switches,etc.): :. /(if resent must be opened)(locate on site plan) DISTRIBUTION BOX: Depth of liquid level above outlet invert: eviden evidence of solids carryover,any ce Comments(note i of f box is level and distribution to outlets equal,any ' leakage into or out of box,etc.): d PUMP CHAMB (locate on site plan) Pumps in workin order(yes or no): Alarms in worki g order(yes or no): Comments(not condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) Property Address: 336 Lincoln Rd. Hyannis, MA 02601 Owner: Spinney _ Date of Inspection: /�Z-- SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation.not:required) If SAS not located explain why: TYPe aching pits,number:_ leaching 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, etc.): / CES POOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Numbe and configuration: Depth— op of liquid to inlet invert: Depth o olids layer: . Depth of cum layer: Dimensio s of cesspool: Materials f construction: Indication f groundwater inflow(yes or no): Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:ts(note (locate on site plan) Materialonstruction: Dimensi Depth ofs: Commen condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 t ' .t Page 10 of 11 OFFICIAL INSPECTION'FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM-INSPECTION FORM PART C SYSTEM ION(continued) 4. Property Address: 336 Lincoln Rd. Hyannis, MA 02601 Spinney , Owner: Date of Inspection: 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. � A M M e d, -01 10 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 336 Lincoln Rd. Hyannis, MA U 01 Owner: Spinney Date of Inspection: rYa 3")-- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water o`Z S 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: bserved 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 ow you established the high ground water elevation: -O W ' a ' r > 'w 11 TOWN OF BARNSTABLE q., LOCATION �3G I jAzc �_/_& 4?J SEWAGE # //-- 3 3,,' 1 V ILAGE �� ASSESSOR'S MAP & LOT .1]'1- IM 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �-q-60 az- LEACHING FACILITY: (type) L4 �wA L. (size) NO.OF BEDROOMS BUILDER OR OWNER PERMrrDATE: :7 2-)-COMPLIANCE DATE: - 7 -9/2 Separation Distance Between the: f Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on iite or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 3&feet of leaching facility) Feet Furnished by I-V (-VJ � � 1� n� o a r r No. Fee 4176 THE COMMONWEALTH OF ASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migool *pgtem Cons;tructfon Permit Application for a Permit to Construct( )Repair(�de( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.'�a(Q w 1Q Owner's Name,Address and Tel.No. �.wti1S Y��YC� G Assessor's Map/Parcel "?71 0 4o 7. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. r2bc&e-E � " ;.,o 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 314c, gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank (S�D Type of S.A.S. 14 6'*v. ne-oYy `t rid►LTr��O� Description of Soil '- Nature of Repairs or Alterations(Answer when applicable) W VV S'e k U c_ iv 6 0 ,.- i 1► c. I • � tt 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 of to place the system in operation until a Certifi- cate of Compliance has o Signed Date 7`Z-17 Application Approved by Date yam` Application Disapproved for the following reasons Permit No. w Date Issued ' r— No. Fee _ THE COMMONWEALTH OF ASSACHUSETTS. Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Digpog l *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(�ade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. _WjC(:AN a Owner's Name`,Address and Tel.No. Assessor's Map/Parcel 7 7 ) C b-7. �I L C tr t G U� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 20 Q (� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3o gallons per day. Calculated daily flow 3`\5 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 14 C c,12 C%r��j=Q\—Tr6t 0 Description of Soil fo Nature of Repairs or Alterations(Answer when applicable) .S�' �` ��J Gk W► 1L- P_ 60K x G rry I UT V-,'i'D Y?S L I STZI Y- e_. o►v S I`(� �'-�` n U K�is N ,Tj (i Date.last inspected:' / ' r7 Agreement: The undersigned agrees to ensure the construction and ma ntenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and of to place the system in operation until a Certifi- cate of Compliance has o t` Signed Date 7 1-1 L APPI cation Dlicdtion isapproved roved for the following re ..;.f T _ r; Date J DPP PP g reasons Permit No. .- Date Issued Zr ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO tj"t the-On-sfte�5eVage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by o at 33 L_-s►v c 40,0 K4NMS has ben constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9dated Installer Designer The issuance of this rmit s II not ' seJ�strued as a guarantee that the syste will function as designed. ' Date � ✓ Inspector -- No. �� '✓ ✓� -------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Dfi6pogar *pgte mongtructton Permit Permission is hereby granted to Construct( )Repair( )Urade( Abandon( ) System located at 3 L i r�.c � ►� CUc �/. 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 t ' t. Date: / /� / Approved 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 DESIGNED PLANS) I, 1 �S , hereby certify that the application for disposal works construction permit signed by me dated �l —V �t7 , concerning the property located at �v3 �-`�wLy`� � `� r meets all of the f. following criteria: • There are no wetlands within 300 feet of the proposed septic system r � • There are no private wells within 150 feet of the proposed septic system �� • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase'in flow and/or change in use proposed J • There are no variances requested or needed. SIGNED : t # DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER � 4 .[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i �';.. �� . y y o -0 ,!t .,__ `'� � v 'r , r + 1 4 ', �� f� �. �,, � K TOWN OF BARNSTABLE LOCATION: 336 ZI&C'n_ 42 A SEWAGE # VE.LAGE"% ASSESSOR'S MAP& LOTS zr,- L 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING.FACILPTY: (type) (size) N0.0F`BEDROOMS BUILDER OR OWN$R R�,. '-, PERMIT'DATE:_T j- )-COMPLIANCE DATE: Separation:Distance Between the: Maximum Adjusted Groundwater Table and 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 VQ feet of leaching facility) Feet Furnished by: . 6 A� �C A Aa-�-. 13