HomeMy WebLinkAbout0064 HINCKLEY CIRCLE - Health 64 Hinckley Circle
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COMMONWEALTH OF NIASSACHUSETTS
EXECTT'I'IVE OFFICE OF ENVIRONMEN'TAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECCIVED
DEC 15 2004
TOWN OF BA;RNSTABLE
TITLE S HEALTH GEPT.
OFFICIAI,INSPECTION FORM—:NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ,
Property Address: t AL 44 CI I JIL I f
Owner's Name-
£®
Owner's Address: r
r Oa6y$
Date of Inspection: , -�
7,
Name of Inspector- pI p 'nt) "o-t Lki E r �
ZZ
Company Name O ,peg uo+�s r1,
Mailing Address: cr) I
MA owu
Telephone Number: IDR.38 --76�
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 DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: l/ o) O
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.
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 1
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: to C�
Owner:
Date of Inspection: ti t X 1 6(ON
insspeefion summary- Che& A,B,C D or E/_ALWAYS complete all of Section D
A. System Passes:
I have-not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
or more m components as described in the"Conditional Pass"s on need to be replaced or
One system ompo
repaired.The system,upon completion of the replacement or repair,as approv y the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the follo g statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the c tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as I ved by the Board of Health.
*A metal septic tank will pass inspection if it is stru y sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is a le.
ND explain:
Observation of sewage backup or out or bigh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, ed or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)a¢e replaced
obstr Aim-k.ttc owed
distdirudon box is leveled or replaced
ND explain:
The syste equired pumping more than 4 times a year due to broken or obstructed pipes).The system will
pass inspection' (with approval of the Board of Health):
broken pipes)are replaced
obstruction is removed
ND explain:
2
Page 3 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: &q v
Owner:yR
Date of Inspection: it 1 ao 014
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fiuther evaluation by the Board of Health in or 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 th 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public Ith,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 vege ed wetland or a salt marsh
r
2. System will fail unless the Board of Health( d Public!Water Supplier,if any)determines that the
system is functioning in a manner that prot he public health,safety and environment:
_ The system has a septic tank and so' absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s ce water supply.
_ The system has aseptic tank d SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic and SAS and the SAS is within 50 feet of a private water supply well.
The system has a sep 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 f the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatil organic compounds indicates that the well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria triggered.A copy of the analysis must be attached to this form.
3. Oth
3 -.
Page 4 of i 1
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �<
FART.A
CERTMCAT1bN(continued)
Property Address: G Cafe
d
Owner:
Date of Inspection: a
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or`moo"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
e Liquid depth in cesspool is less than 6"below invert or available volume is less than'h 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.
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 loboratory,for coMorm 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 equat 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.]
1� (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 nwst a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must indicate either"yes"or"no"to each the following
(The following criteria apply to large syste in addition to the criteria above)
yes no
the system is within feet of a surface drinking water supply
_ — the system is 200 feet of a tributary to a surface drinking water supply
_ the syste is located in a nitrogen sensitive area(Interim Wellhead Protection Area—AVPA)or a mapped
Zone of a public water supply well
If you have rered"yes"to any question in Section E the system is considered a significant threat,or answered
`yes"in on D above the large system has failed.The owner or operator of any large system considered a
sign t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR
15.304.The system owner should contact the appropriate regional office of the Department.
A
r ,
Page 5 of 11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMMNI TS
SUBSURFACE SEWAGE DISPOSAL SYSTFM INSPECTION FORM
PART B
CHECXLIST
Property AZRO
Owner: ,�
Bate of inspection: 1 120(L
Check if the followinghave been done.You must indicate es"or"no"as to each of the following:
`�1 - —
Yes No
pumping information was provided by the owner,occupant,or Board of Health
/r Were any of the system components pumped out in the previous two weeks?
K Has the system received normal flows in the previous two week period?
_ 0( 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)
y _ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
L _ Were all system components,excluding the SAS,located on site?
C _ 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:
Yes no
_ Existing information.For example,a plan at the Board of Health.
o,( _ 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(3)(b)j
5
Page o of I I
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address
Owner:
Date of Inspection:
FLAW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actuaI):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: 0
Does residence have a garbage grinder(yes or no):Pb
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no)-AJO
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15203}; apd
Basis of design flow(seats/persons/sgft,e .
Grease trap present(yes or no}:
Industrial waste holding tank pr t(yes or no):_
Non-sanitary waste dischara to the'Title 5 system(yes or no):T
Water meter readings,if ailable:
Last date of occupan use:
OTHER(desc e):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:_____gallons—How was quantity pumped determined'
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,sou 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 of all cp�Ponen 'date insta if source of information:
PP age kit
Were sewage odors detected when arriving at the site(yes or no): AoA0
6
Page?of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
J SYSTEM�` INFORMATION(continued)
/�
Property Address: 61
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan) .
Depth below grade:
Materials of construction:_cast iron J40 PVC_other(explain):
Distance from private water supply well or suction Iine:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: V (locate on site plan)
Depth below grade: cX
g tr
Material of construction: V 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) ff
Dimensions: 1 Sb0!jC l
Sludge depth: Q 0
v
Distance from top of sludge to bottom of outlet tee or baffle: '5D
Scum thickness: _ p
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or bfle: l �(
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related tA outlet invert,evidence of le
e,etc a .)
a I it Le
iwJed`
GREASE TRAP:_(locate on site plan)
Depth below grade: :
Material of construction: concrete_metal`fibe glass colyethylene other
(explain):
Dimensions: _
Scum thickness:
Distance from top of scum to lop of autle a or baffle:
Distance from bottom of scum to bo of outlet tee or baffle:
Date of last pumping:
Comments(on pumping re-co
endations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, idence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.Property Address: ` Lk c�9-e
Owner:
Date of Inspection: !t d'
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal rglass polyethylene other(explain):
Dimensions:
Capacity: gallo
Design Flow: g ns/day
Alarm-present(;yes or no):
Alarm level: Al working order(yes or no):
Date of last pumping:
Comments(conditio alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4?V&I
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage bu�tto or out of box,etc.}: / ,
b c x c) ass (V vc�C �t� Cc� Jf7�r ✓W s tc cc c4 6c rmeo&s4
PUMP CHAMBER: (locate on site plan) ,
Pumps in working ordX;es
Alarms in working or
Comments(note condamber,condition of pumps and appurtenances,etc.):
- 8
Page 9 of I I
OFFICIAL.INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS
SUBSU FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C i
SYSTEM INFORMATION(continued)
Property Address: Ce�9 ,
Owner 1& '
Date of Inspection:
SOIL ABSORPTION SYSTEM[(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching 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.):
OND
hw t .a
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 constructio .
Indication of ground er inflow(yes or no):
Comments(note c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
x.
PRIVY: (locate on site plan ;
Materials of construction:
Dimensions:
Depth of solids:
Comments(note co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page l0 of l l
OFFICIAL INSPECTION FORM[-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Date of Inspection: 11 Z&A Dq „
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 eaters the building.
t ti i
Y
t
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_ M
PART C
SYSTEM INFORMATION(continued)LProperty Address
Owner: O
Date of Inspection:
SITE EXAM
Slope �46
Surface water 00
Check cellar 6
Shallow wells
Estimated depth to ground water—2,'�'feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 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 later elevation:
11 ,
TOWN OF BARNSTABLE -` r, [�
LOCATION dl/,17114C ,. ���� SEWAGE #
VILLAGE D�T`7rNr��//e_ ASSESSOR'S MAP & LOT [Y).- O,&'4
INSTALLER'S NAME&PHONE NO. //k.,91-11 C t Z
SEPTIC TANK CAPACITY /S®O ��/•
� r �
LEACHING FACILITY: (type)CC-/� 330 (3) (size) Io De C26
NO.OF BEDROOMS -3 1
BUILDER OR OWNER AAA CMs bZ
PERMIIDATE:_ �t (o-t SS 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
e_
CAz
-UTT�.
3NIk �
y�� D,s[ -0 1.1316
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Y
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0[pplication for Digozaf *p$tem Construction 30Crmit
Application for a Permit to Construct( )Repair(1/')Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. <?C° 7 !e' C Owner's Name,Address and Tel.No.
QS/�',evr/114"
Assessor's Map/Parce�1y DS-5—
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwellin No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4/0aac % /5ao w9 1 - �s D Sg'i ,
L��c5>4. � or, l� ST��L 3Is
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 iss�dd by this oard of al
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. e' Date Issued 43 �' ��
sy�,r
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
YY,
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0(pprication for Migogar bpgtem Conaruction Permit
Application for a Permit to Construct( )Repair(il-)Upgrade( )Abandon( ) ❑ 'Complete System ❑Individual Components
Location Address or Lot No. i/1 C r/ I Rc C c Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
A OSs
Installe-r''ss Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
wellin No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 400FA2 c TO
3- C.,1
1
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 iss -d by this,oard o ea h.
• Signed .c - Date/T��
Application Approved by Date r•
Application Disapproved for the following reasons
x5.
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (Upgraded( )
Abandoned( )by 4xly r20 S I-
at ��t��c`��� C,re. e SiP v,/ P has been const cted in accorda ce
with the provisions of Title 5 and the for Disposal System Construction Permit No. '' dated �'
Installer �I c c c (`,i T�r Designer
The issuance of this permit shall t be constrld as a guarantee that the system will function as designed.
Date .4,6- /Ji/�S% � � �� ' 1 � Inspector
- No.� �--�--------------------------Fee y�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigogal *pgtem Congtruction permit
Permission is hereby granted to Co 'ct� ) epair(j,"')-Upgrade( )Abandon( )
System located at 61_/f/1 n / Ci E?c 6 %c',-v r;Ir
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 thi t.
Date: lql f, f /� Approved b ,
f I
o
1/6/99
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)
h M ce 0.cr-A -S-Tr hereby certify that the application for disposal works
construction permit signed by me dated au c 1 14 c'Gi ; concerning the
property located atr�\c- meets all of the
b
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling. /
t
• The soil is classified as CLASS land the percolation rate is less than or equal to 5�minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested gr needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 3 8,"1
B) G.W.Elevation +the MAX.High G.W. Adjustment.
DIFFERENCE BETWEEN A and B ,Q
SIGNED : DATE: Ave_/D F-
[Sketch proposed plan of system on back].
q:health folder:cert
r
Q O
1
1_17
l
TOWN OF BARNSTABLE ► �"' _�f86
LOCATION SL21 >/���/ ( '��'" -- SEWAGE #
/�
VILLAGE ASSESSOR'S MAP & LOT
L1���.z�l/e
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY TOQ 6`W
: .33 cc 0 3) (size) 10 X 026
LEACHING FACILITY: (type)Cy/
NO.OF BEDROOMS -S
BUILDER OR OWNER " �n'
PERM ITDATE: A l t u—l COMPLIANCE DATE: g 2 ��
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
I
a be
�? 71
............ �1 l
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