HomeMy WebLinkAbout0295 REGENCY DRIVE - Health 295 Regency-Drive
Marstons Mills P
A = 064 040
i
r
RECEIVED
DH` E /1 10-MAY 2 8 2003
PROPERTY ADDRESS:295 Regency Da.ive TOWN OFBARNSTABLE
----------------------- HEALTH DEPT.
MVv
.4-®
PARCEf. ; _ ® 02648
LOT
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1. 1- 1000 ga2ion zept-ic hank.
2. 1-Di.4t21Pxut.ion &ox.
3. 1- 1- 1000 ga2.Pon p2ecazt hexagon .2each.ing pit.
Based on my inspection, I certify the following conditions:
4. 7h.i- i.6 a t.itie Zive use/2t.ic zy,3tem. (78 Code)
5. The hept.ic zyatem .iz .in pAopea wo2k.ing oadea at the paezent time.
6. Oa.3te wate!c iz 58"^ ge.2ow the .invent pipe of the ieach.ing /2.it.
SIGNATURE:
Name:—J.P. Macomber Jr_______
Company: Joseph_P. Macomb er_& Son , Inc .
Address: Box 66
Centerville , Ma . 02632-0066
--------------------
Phone:— 508-775-3338
--------------------
THIS CERTIFICATION DOES NOT CONSTITUTES A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cess pool s-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
0
f
-\ COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 295 Regency Dative
Mnn,s#nnA N 'i;-6,
Owner's Name:JozeRh Cohen
Owner's Address: 3¢me
Date of Inspection: 5179103
Name of Inspector: (please print) Joseph P. Macomber Jr.
Company Name: Joseph P. Macomber & Son Inc
Mailing Address: Box 66
CPnt pryi 1 1 P Ma 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
1 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:
4 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fa'
Inspector's Signature: 1'�Gl `� Date:
The system inspector shal ubmit 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 I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:29 5 Regency Dlt ive
ma"Z,6z`on-6 l7i �, mazz.
Owner: JoheR h Cohen
Date of Inspection: 5/19/0 3
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.crit��r)a described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are'indicdte"elow.
Comments:
7hn tonfir tii/fam lit In aaO_Re2 W02/CinU o'2d22-.ai- .the,
i n a o
nn A0 fim
i�
B. System Conditionally Passes:
_2& 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 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.
ND explain:
_6 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:
/UC 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:
2
.1
--` Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:1O.seIh Cohen
295 Regency Dz- ve
Owner: l a.,zz t on 6 l'li if,3, Na.6.6.
Date of Inspection: 5/1 9/0 3
C. Further Evaluation is Required by the Board of Health:
,00 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
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
Ab The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
�l3 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water suppl}.
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,bgJ50 feet or more from a
private water supply well". Method used to determine distance
"This system gasses if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ao,3 e h Cohen
795 i
Owner: t7a/th1-one a.6.e.
Date of Inspection: 5/1 9/0 3
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
VDischarge
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
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
Jcesspool )—,LXJ401) Cott)
_ squid depth in Qe"peel 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.
y 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 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.]
AJJ (Ye"o)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
[1 the system is within 400 feet of a surface drinking water supply
e 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.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 295 /2e c/encu D z ive
//����c,.�#nn.�
Owner: ao�e�h�Lo en
Date of Inspection: 5/9 9/()?
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
_zWere any of the system components pumped out in the previous two weeks?
--t/ — 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?
4ZI_ Were all system components,XKluding 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:
Yes no/
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(3)(b)J
5
f
Page 6 of 1 1 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 295 Regency [hive
a2�S ORb L b� alb.
Owner:ao,6 e/zh Cohen
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL � d
Number of bedrooms(design): Zl Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: X
Does residence have a garbage grinder tyes or no): .60
Is laundry on a separate sewage system(ye or no):. [if yes separate inspection required]
Laundry system inspected(yes or no): I� the we.P.P h a z 2 o t Peen
Seasonal use: (yes or no). .t e,3 t ed .in .the /?a.6 t 72
Water meter readings, if available(last 2 years usage(gpd)): P o n t h . It hu o Pd e done
Sump pump(yes or no):�D
Last date of occupancy:_ „mil j at .t h.i.6 time
See gageh 64 & 613
COMM ERCIAL/LNDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): 7X gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present (yes or no):/j2Z¢
Industrial waste holding tank present(yes or no):.140/4
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe): vf�/
GENERAL I�FI~O�) ATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): tt
If yes, volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping: 141/¢
TYP�E 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 AJ Attach a copy of the DEP approval
Other(describe):
Approximat aee of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):AV
6
Page 7 of I 1
OFFI -;-L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
S1 .:SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) .
PropertyAdr ,s: 295 Reyenc Derive
u2,6 onh
Owner: Cohen
Date of Insp f, . n- 51191D
BUILDING ` VER (locate on site plan)
Depth belov,, 1
Materials o-1 c ruction: _cast iron /40 PVC,jj�other(explain): /Ji4
Distance frog: .,vate water supply well or suction line: /d 'yt
Comments (o-. .. ndition of joints, venting, evidence of leakage,etc.):
o 1nt ;__n. eaA t.iahi No evidence o� eeakage The 6yate-m i.6
vented onyh the 2oo� vents.
SEPTIC T:;: / (locate on site plan) 14-5,100,6 •'us
tt
Depth below , e: 46•
Material of co. uction: Q/conerete4Zg4 meta k�fiberglasW6polyethylene
0•t�jjother(ex X7
If tank is met-. age: Is age confirmed by a Certificate of Compliance (yes or no):. (attach a copy of
certificate)
Dimensions:
Sludge depta:
Distance fro::: of sludge to bottom of outlet tee or baffle: /�idGCi
Scum thickr \
Distance frog. c scum to top 0Poutlet tee or baffle:
Distance fior. om of scum to bottom of outlet tee or baffle:�
Haw were e:: D.-is determined: {
Comments(: .;wing recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related ,e i.nveri, evidence of.leakage,etc.):
Pum12 tr'i , of cc funk eve2y 2-3 yea2,6. Zn.{et 9 OutQet tee.6
ate in e. lhe tank .ins 6t2uctultaP2y Sound and 6how.6 no
ev.idenc, .9eaka ye.
GREASE TI . z Jocate on site plan)
Depth below
Material of- _tion:1U concrete4&f metakAfiberglasW�polyethylena��other
(explain):.._ . �Ll�fat'
Dimensions
Scum thick: : _
Distance d-c:,. t scum to top of outlet tee or baffle: Ally
Distance frc-. )m of scum to bottom of outlet tee or baffle: d2!�?
Date of last
Comments (c ping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to <. avert, evidence of leakage, etc.):
GnP0An _; d.A nnf nnv.tvnf_ `
7
J Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:295 /2egency D z.ive
0a2.6 one .c ,6 0aa,6.
Owner: o,6e�h Cohen
Date of Inspection: 5/19/03
TIGHT or HOLDING TANK.&Jextank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 16L4
Material of construction: 10 concrete metal fiberglass ? po)yethylene4,Hother(explain):
Dimensions:
Capaciry: allons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: _/,�f Al in working order(yes or no): -tO
Date of last pumping: /i
Comments(condition of alarm and float switches, etc.):
l.i t o hoid.ina ;tank-3 ate no /?/ze.6en
DISTRIBUTION BOX: t/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: .(�d
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.):
Di,6t,z.igut.ion box ha,6 one iate2ai. No evidence o/ ,3oiidz ca2/zy
Qum,.. No evideizce o� eeakage .cn o o2 out o e ox.
PUMP CHAMBERI.1,k/e,(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.):
um.12 chamge2 .i.6 not R2e.6en
8
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 295 Regency Dlt ive
(Ia2,6t on,6
Owner: o.s Rh Cohen I .
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
1- 1000 ga eion /:/cecaet .Peach.ing /Z.it.
If SAS not located explain why:
Located: See 12aae 10
Type
1/leaching pits, number:
d leaching chambers, number: d
leaching galleries, number: 65
leaching trenches, number, length: cl)
leaching fields,number,dimensions:
AM overflow cesspool, number:
innovative/altemative system Type/name of technology: y�Qijj�. C�7e-���>
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
LoamU hand to goney medium .6and to .ine .6and. No h.i nz o h d2auPie
�ni Puna nn �nonding So.iea a/ce d2y. Vegetation iz no/zmae.
CESSPOOLSL&)e.(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: O
Depth—top of liquid to inlet invert: lyfA
Depth of solids layer: �O
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: J /Q
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
CP t.snooP t a/ze not 12/ie.6ent
PRIVY/t�,A, (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.):
/0/7 r iA nnf 4,nv,5vnf _
9
Page 10 of f I c:
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address.
295 Regency [hive
17 a2a t o n z 777TT( al ,6.
0woer.1oze/2h Cohen
Date of lospecdoo: 5119103
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.,�Vater supply enters the building,
s
/w
t i
a9 5 Re,bOn C-L
10
Page•11 of I 1 '' e
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:29 5 2e genct/ D z ive
Nanh.ton.6
Owner: o.6el?h Cohen
Date of Inspection: 5/19/0 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water /M feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: NA
qES Observed site(abutting property/observation hole wit%150 feet of SAS)
NO Checked with local Board of Health-explain:
qES Checked with local excavators, installers-(attach documentation)
y�Accessed USGS database-explain:.hil-12:Ili-own. ga2nb.t agtoe. ma. u.6.
You must describe how you established the high ground water elevation:
LLzed, O une1992
LLaed: LLSG . /ec n.ec_a u e .en - - / ia.te #2 Rnnua2 zan.ge.6 o� gzound wate2
wa e2 eke c .S'. aanuajzy 1992
Leaching
Pit Id 6 .ect
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is �!
feet.
11
TTT�nlTl�T�\rRTJIR'/1TTfTTRiRT.ITRIST'�STnTl�T'1r1'1 lu .. �•
ra T
TOWN OF a2n� BOARD OF HEALTH
0 T,-T •-T �-,SIIIISUNFACF 9F.WA()F_DISPOSAL SYSTEM INNSPECCTION FORM - PART D .- CEwriFICATIUN
-TYPI OR PRINT CI.EARL1•-
PROPERTY INSPECTED
STREET ADDRESS 295 Regency Derive P1¢2etonz Niiiz, tlazz.
ASSESSORS MAP , BLOCK AND PARCEL # 064-040
OWNER' s NAME aozeph Cahen
PART D - CERTIFICATION I
NAME OF INSPECTOR _ Joseph P. Macomber Jr..
COMPANY NAME Joseph P. Macomber & Stln * Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Strvvt Town or city
Stat• lip-
COMPANY TELEP14ONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 _ 1 578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
Drecoinmendatiorls
his address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was
i•e ardill u Performed and any
this
g pgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Ch27System:
one :
PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
heall:ll ot• Lhe environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED$ \
The inspection which I have con �icted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this. inspectio form .
V
Inspector Signature t
Date
copy of this ert.ification must be provided to the OWNER, the BUYER
D766
where aJ?plicable ) and the DOARD OF HICAL711.
* It the inspection FAILED, the owner or""operator shall u
he
within one year of the date of the inspection, unless alloweddortrequiredaYstem
otherwise as provided in 3.10 CDIR 15 . 305 .
partd .doc
TOWN OF BARNSTABLEj
:10CATION 295 Regency D/zive SEWAGE # 5/y`
VILLAGE Na2ai-ons NiU,6, lea,3-6. ASSESSOR'S MAP & LOTU64-040
INSTALLER'S NAME&PHONE NO. a. P. M a c o m P-e,,z 2.
SEPTIC TANK CAPACITY 10 0 0 g a ie o n,6 I-Box I n,6 p e c i i o n
LEACHING FACILITY: (type) I-LP- 1 U 0 U (size) 1500 ga e i o n,
NO. OF BEDROOMS 3
BUILDER OR OWNER IozeRh Cohen
PERMIT DATE: COMPLIANCE DATE: 5/1 9/0 3
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 3100 fe t of leac ' g f Feet
b Furnished
An
i
t /c v
,y
ag 5 ` Q,5wC-Lj 8,r-
TOWN OF BARNSTABLE
LOCATION �?qS SEWAGE #,.:_..:
F VILLAGE S L2 04 S ILZ.S ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
CAPACITY 1 C>�
SEPTIC TANK C b a
C
LEACHING FACILITY:(type) (D k doh (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER � -
BUILDER OR OWNER d,f=f+ Af) C-h
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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