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HomeMy WebLinkAbout0024 SEA ROBIN ROAD - Health PI 24 Sea Robin Road Marstons Mills -. - -- A = 122 039FPO � \ u A I i i I r V 0/6 COMMONWEALTH OF MAMSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION v TITLE S OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A L� CERTIFICATION Property Address: / Se Gj A a 6,y P`J e0 /e D� S� Owners Name: 2 R f e—Z / Owner's Address: e� v �Gt,-5 TO 8 , Date of Inspection: j �j QS Name of Inspector:(please print) Company Name: Mailing Address: o Telephone Number: �oz7 9 CERTIFICATION STATEMENT 'y I certify that I have personally Y 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 S n 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ils Inspector's Signature: -de Da te: /> Q; The system inspector shall submit a copy of this inspection report to the Approving Authority oard 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 f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �P. Tc o d b�h Qj D 6 Owner• �- � Date of Inspecti g e Inspection Summary: Check A,B,C,D or E ALWAYS complete all of Section D =Ses' 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: ?One or more system components as described in the" „ r Conditional Pass section aired need toor repaired.The system,upon completion be replaced will Po mp n 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: 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: Tit1a 4 Tnannn*inn Tlnr... Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A (� / CERTIFICATION(continued) • Property Address:— / ti Jed D S ►ryl Ile, �65� Owner: AveQg � Date of Inspection: g C.�Further Evaluation is Required by the Board of Health: ./v Conditions exist which require further evaluation by the Board of Health in order to de is failing to protect public health,safety or the environment. determine if the system 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(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 Cessp ool o_ p r privy 1s 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: _ The system has a septic ep tank and soil absorption surface water supply or tributary to a surface wter supply. m(SAS)and the SAS is within 100 feet of a _ 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 finm 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 colifonn 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: T41a 4q Tnannnfinn l:nrm 4/1 g/^lnnn 3 r ` Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C2 �T leGi Owner: O�cs5 Date of Inspection• r� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No t ,/ kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Dis harge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ogged SAS or cesspool — he liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — _Jcfquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow (/R�flaired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number fttimmes pumped — y portion of the SAS,cesspool or privy is below high ground cater elevation. wAny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ater supply. y 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 performed at a DEP certified laboratory,for conform bacteria and volatile orga supply well with no acceptable water quality analysis. ]This system passes if the well water analysis, nic 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 is 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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The follo ' g criteria apply to large systems in addition to the criteria above) yes no _ 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 stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 Departrnent. Title C f .....:.._ r.--- i i.... 7 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: *--v( Owner: /4/V Date of Inspection: 0� Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes. o 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? �HH the system received normal flows in the previous two week period? Have large volumes arg es 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? Were all system components,excluding the SAS,located on site? —Z— Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the b es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _7_ 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 o 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 CUR 15.302(3)(b)] Title G Tncnnn*inn 17nrm 4/1 IC/)Ann 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l SYSTEM INFORMATION Property Address: I seed Owner: 2e Z Date of Inspection: g 0.5 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder,(yes or no): Is laundry on a separate sewage system yes or no):-/TV [if yes separate inspection required Laundry system inspected(yes or no): 0 Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): IVn Last date of occupancy: C LILT" COAIMERCIAL)INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Vd Basis of design flow(seats/persons/sg8,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): Pumping Records GENERAL INFORMATION Source of information: �iP k/ f f-�e-7 Was system pumped as part of the inspection(yes or no):itio If yes,volume pumped:_gallons-How was quantity pumped determined? Reason for pumping: T SYSTEM eptic 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/Altemative 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): /60 Title Q Tncnnrtinn C.......L/t einnnn L Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ✓v i ��6.Sjr' Owner: Vq Z_ Date of Inspection: g OS BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: D_cast iron PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(` locate on site plan) Depth below grade: ld -1 Material of construction: concrete_metal fiberglass_polyethylene _other(exphdn) — —' If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) , Dimensions: 1p N (0 Sludge depth. 02 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Lem— / /i Dist ance from top of scum to of top outlet tee or baffle: Distance from bottom of scum to bottom ppf outlet t or baffle: II How were dimensions determined: le -94 CC Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels asplated to outlet invert, vidence of le g ,etc.): GREASE TRAP; (locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural inte as related to outlet invert,evidence of leakage,etc.): gritY,liquid levels Title G i,....a.r:... O _.. ell a�nnnn 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: Owner• �� Date of Inspection: TIGHT or HOLDING TANK: Al—(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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: V90/✓`' ti L Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out o o etc.): /Lo So/ ril PUMP CHAMBER: /Is (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.): J ° Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � ' �i �o�,�, R'j Owner: /¢ vex /'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: e5 leaching galleries,number: ✓ti erg 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.): / O N N or Lj` // .L r j/e SY.I., /�-�-- 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: ocate 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.): T.O. c T------:.._ r —Zrt a rn nnn Q Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Via, Jqa zz", d /lift Owner: 14/✓"Tre Date of Inspection:_3�L 0� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benc ks.Locate all wells within 100 feet.Locate where public water supply enters the building. l rQ N I � Q T41a i fnanAotcnn Rnrrn 10 " . Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C�—� �� "e0 6�1-7 /?G/ 74 Oo2 6>r/— Owner• ✓,A Date of Inspection: 0- SITE EXAM Slope Surface water Check cellar Shallow wells r Estimated depth to groundwater /O feet Please indica ck)all methods used to determine the high ground water elevation: btained 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 water elevation: G1 of o�► � e G/,,,' O T41a 9 T»cnan4.in.. 1:..— tit f I^— 1 7 OF B LE3 /� Y./ LOCATION SE E #'�Q� TIO jj VILLAGE ASSESSOR'S MAP & LOT/2-2— ' INSTALLER'S NAME&PHrE NO. SEPTIC TANK CA06 P CITY1 5 00 LEACHING FACILITY: (type) (size) O � NO. OF BEDROOM BUILDER OR OWNER �S PERMITDA COMPLIANCE DATE: ' U Separation Distance B tw n 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, i �� . � � , f i �i �� ZS 1 f �a i qq-�� >> V '�� Z , , �� � � �,� 6 � _ �_ � �i �. 3� , 6 ,� � 3?, �� `� s , . �' 3�- f iM1 No.C� l� THE COMMONWEALTH OF MASSACHUSETTS FEE ��VV BOARD OF HEALTH C Ter" OF 64n41 S T" (-+G APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (pair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components Z + S 8)4. 20 b/ k o ^+ ► L 7n7+/ 9"ff-S 2 Z 3 9 Location 100 e 0 X 12f s y 4 Map/Parcel# 7 7/ 1`91 l p Loth 'a^ Leff 0el�Tel�p�one# ZO ' Name /(j/ /f,/Iot 0-2("q 16of >ri L-D JCJ U J ^Ad re� l ) Mot /—i`>s „` —4_0 8 adV5— Telephone# -1 Telephone# Type of Building: r_LsS 10e-J T-I F}L Lot Size 43, 5 Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder (n/Q Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.re uired 330 gpd Calculated desi n flow gpcllF/Z Design flow provided33Z)gpd Plan: Date © Number of sheets _ Revision Date Title �Lf37' 91� Pit d P6 S'<-f� Hoy S_ Sr Ajt/iLG,A-Gls X LL' 4.6 V,pis POSfK d S�✓my rI s�vy /s 9y�_ Description of Soil(s) ©—/D 1 0*"1 �� Soil Evaluator Form No. Name of Soil Evaluator �. �✓/LSo n/Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS /✓Lrl✓ C(T.,J f T2UC '1t p^j The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a7xAt to place the system in operation until a of Compliance has bee issued by the Board of Health. Signed Dates w s FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ' .. vp.,s,i.���,., .. w�.r'r'.y.-rk�k`f 7"�, k .. ..w"b �.,« .+..n. -. `'•,,.r•-. , e� . o. ..,<�.,1� ^..�'. ... '' .. .... •v. No. _ll✓'� THE COMMONWEALTH OF MASSAC:HUSETT! " FEE �~ BOARD OF H EXLAT"H -- -=- OF 5 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT 11111,Application for a Permit to Construct (j/�Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components / f 2.Z J / I'1 Location Po 6V I zf rs " I Map/Parcel# i Lot# Tele ho7ne/# v a a l� lsS Ocs3! �v f o, x �j 2_ s Name7GiCf FY I'`R O204J 16�9j�Q JX41--74 LD V*_5 )5 rM«� Ad re _7 e/(J TO qd V Telephone# Telephone# Type of Building: S I i0wj T'I A L 00t a L IW 4 Lot Size,4' 5(Z Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder (n/0 Other'-Type of Building No.of persons Showers (Cafeteria ( ) Other fixtures to ,,- Design Flow(min. e uire 3 Q gpd Calculated design flow�j V gpc��� Design flow provided330 gpd Plan: Date 0 Number of sheets . Revision Date Title /L fJ1- �[tsar/ p2 d Fb S A fF�y S 4- Stejy4FA.C.65- SC A G y— AJ PoS,+1_ SYS; „ s o y 40 "4&W, " . Description of Soil(s) (!"-�� LL Urar�1 `4/A� ��" 30 �6 04-M Q� 3 A'`� 7 � Soil Evaluator Form No. � -� Name of Soil Evaluator _V, All L SD Al Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS �✓LrZ✓ C Q r S rn UC rl C>^j j i The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree of to place the system in operation unfit a 'rh dt of Compliance as bee iss edby the Board of Health. Signd° VU4 Dat s Ck FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 a No. r y I ` T E COMMONWEALTH OF MASSACHUSETTS FEE 1L ,f� �P I BOARD OF HEALTH ,.•' CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed(1-- epaired( ),Upgraded( ),Abandoned( ) by- at �� ,QCG. c> I has been installed in accordance with the provisions of 3_1q Q4R 15.00 (Title,5) and the approved design plans/as-built�..,,., tarts gelatin to application No ':dated (11l» Approved Design Flow d P g PP PP g (g, ) Installer Designer: Inspector I / �DL '12 L)3 C� l The issuance of this certificate shall not be construed as a guarantee that the system will function as designed/ FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 ;x• No. � . �� THE COMMONWEALTH OF MASSACHUSETTS FEE �"v^ (ZtU kC �A BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct 1(/rRepair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at D9 �f�c. C`,� i r-N NQ(4 L -y�tll��Q r as described in the application for Disposal System ons ruction Permit No.'��'' 1 dated Provided: Construction shall be m ete wit three years of the date of this p it 11'� conditi o mt be met. Date Board of Health FORM 2 - DSCP DEP A PROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBSB WARREN rM PUBLISHERS- BOSTON bOF B LE LOCATION SEWAGE #.�—D6 1 ) j VIi,LAGE / ASSESSOR'S MAP &LOT/2-2— ' D3� . i INSTALL�ER��8��t PHQN�O. . SEPTIC TANK CAPACITY t lSoo LEACHING FACILITY: (type)'.' SC Z (size) © � NO. OF BEDROOM BUILDER-OR OWNER. ' PERMTTDA • COMPLIANCE DATE: -� Separation Distance B tw n the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet j 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 t� i r 1bIq o o Zo I -n-T 2 ' 6 -Fmo-.ECnM(Wk rtt-) j ...---.._._.._..._—..._.._ _......—.__._ AUJMr quR . r r r fi` - - - a.m.rMORS r T- r r r_ 0 cfMAR CLAP&94 INsu c4n.u. I j� -N� _1R1_PS.S'�WLtON\V�48"... REn vk5 r . I . I� F I F I F- I .. V2IIWNr> :n.. APROy.. J7ROUT-.ELev?XTlOr4' 14.0' . 1 At- 1 o I 12.12 DESK 1 i I , , j 1 5-03 ` g�-0.. - b.p" 1 10.6` .. ... .� ��� I � Qb�• Il'o- _._— tOO--_ tf tq m; N LI PAIMEA:.SU-.fTE O 2' I _.pIN1NC, '. 5° hE2QCOM m j a S O 2.4' 4.2" 7.6- � 2p.tO'• CLA. _ rF 3G .6191 14.,r 2-WIn.o- s 2001 I t i — � i I j ' • i s.b- -t:z•• I s.b- s:o• y.b- I �=o• 9�0- ...--------._.__..... .... .. � 8 co. i z O L.. :_.._. .. -......-. _........_-. .... . ... :. :. EEEE Preliminary plans and layouts by D.C.D.are for the use of their customers only.Any other use is strictly Prohi bite � � Y ♦ I I (r4;p•• O•/l. 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I t 1 ` .2xd_B'O.TTS/.1 .t E ' een PAO nl..'ri.. 06 cwr e ,_ s•`IP"-cn5=:. -_2xe.aa.:io(scy'..:_--..:.. Bi)i.Ts--._.:. `� r2•�nT+c,+oe Iv>LTs _... � •:, ....... _.OFF�-"..fJETiC-1�.... ... l�r• � FR3�6T w.l�L.f�ET/1:�LC`Yz':io� - ._1�f'-i['"�FZ'1"CC��.fj�Z.PI'.•.O� � � �� � �� •�.� i -2aA10 RJDCF- . -2 in.RA.cttAg ... 2-to !�Z' Suenn.11tvq . .Irv.SREATss1A(cv. .... 2.10AFAM.R AF1ER 22 c8 FRbNT RAFTL45 1" ], zz 2.c9 COlU2TE5 C COt[AK.T1E9- 14 IFQS Ix:T_RRA?FS;\l NT \ \\ -- SCALE DATE aJS-JatSTVI; N yy 508.428.6191 !p •r `v. Mevi i n •'9J4:T-44 cwwczi2-ti___ arc-TWs:e VLOOR CailJsfOnf - - — designs - - ----� n.•;�. � -. copyright®2001 All Reserved d 1 c O � S 1 J l - Preliminary plans and layouts byD.C.D.are for the use of their customers only.Any other use is strictly prohibite