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Home My WebLink About0515 WAKEBY ROAD - Health L515 Wakeby Road Marstons Mills P A = 028 050 J f COMMONWEALTH OF MASSACHU SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C DEPARTMENT OF ENVIRONMENTAL PROTECTIOI`I MAP �2 PARCEL LOT TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. A,, ; IYc,o Owner's Name: Owner's Addres c G ' i A, �d Date of Inspection: Name of Inspector: lease print) r Company Name: f. e Mailing Address: Telephone Number: j� T lot CERTIFICATION STATEMENT Doti ' Y 1 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 ection 15.340 of Title 5(310 CMR 15.000). The system: 7p Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: j r Date: / ` ? The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. 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 s f Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address: .,9 - Owner: ' Date of I e t on: Inspection Sum mary: Check A B, ,D or E/ALWAYS complete all of Section D A. System Passes: 1� I have not found any information which indicates that any of the failure criteria described in 310 CMR I5.303 or in 310 CMR 1.5.304 exist..Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the-"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years.old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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: . 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Ppe4ton. ! Z57 2203 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is nit 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 wil .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 tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface Ovate-r supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private wate-supply well**. Method used to determine distance **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. 3. Other: 3 Page 4 of I I OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ;oo o ll Owner: U__ Date of I e twn: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow I/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped _ V Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. 1/ 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.] "0(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 10,600 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a sianif cant 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: -1: Owner: - Date of p c ion: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping.information.was provided by the owner, occupant, or.Board of Health ✓Were.any of the system components pumped out in the previous two weeks L,---_ Has the system received normal flows in the previous two week period? VHave large.volumes of water been introduced to the system recently or as part of this inspection? L/ 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? LWere all system components, excluding the.SAS, located on site.? ` _ Were the septic tank manholes uncovered,.opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was.the facility owner(and occupants if different from owner).provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site.has been determined based on: Yes � + 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)] 5 Page 6 of 11 OFFICIAL INSPECTIONTORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL; SYSTEM INSPECTI.ON FORM PART C SYSTEM INFORMATION Property Address: 5/� C� . Owner: Date of In ection:. S (xJ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): .. DESIGN.flow based on 310 C R l 5.203 (for example: 11:0 gpd x of bedrooms): l V Number of current residents: f Does residence,have a garbage grinder(yes or no Is laundry on a separate sewage system (yes or n f if yes separate inspection required] Laundrysystem.inspected es or o y P (Y 0 Seasonal use: (yes or no): Water meter readings, le(last 2 years usage(gpd)): we,1*- _ Sump pump(yes or no): V /�� /��,�✓� Last date of occupancy: �/�� L� COMMERCIAL/INDUSTRIAL/`"W Type of establishment:.. Design flow.(based on 310 CMR.15.203): gpd Basis of design flow('seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER.(describe): GENERAL INFORMIATION Pumping Records �/ , Source of information: AttlA Was system.pumped as part oft e inspection(y or no): If yes,,volume pumped: gallons---How:was quantity pumped determined? Reason for.pumping: TYP OF SYSTEM .'Septic tank, distribution box soil absorption system rP Y _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): A ' oximate age o all components,.date i talle .(if known)and source of information61 Were sewage.odors•detected when arriving at the site(yes or no) 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / ,4 Owner: Date of �pc n: BUILDING SEWER(locate on site.plan)� Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain).-- Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: ocate on site plan Depth below grade:u �oncrete Material of construction: . _metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a.copy of certificate) Dimensions: `Xr�z Xg Sludge depth:60/1 Distance from top ofsludge to bottom of outlet tee or baffle: 3Z- 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: How were dimensions determined: Comments(on pumping recommend tions, ' let and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert, evi ence of leaka- etc.): r 45 , Al GREASE TRAP:/ ocate 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 integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 r Page 8 of 11 , OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART C SYSTEM INFORMATION(continued) Property Address: ,j i' w� ` ' A Owner: Date of p ton: s� TIGHT or HOLDING TAN`: -(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 fast pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION`BOX: i/ (if present must be;opened)(locate on site plan) Depth of liquid level'above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of kage into or Out of box,etc.): al PUMP CHAMBER/&'(locate on site plan) Pumps in working.order(yes.or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,-condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . Owner: Date of p ction: osC)OQJ SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, excavation not required) If SAS not located explain why: Type leaching.pits, number:_ 1 ching chambers, number: leaching ga_leries,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. —OX4JJ,�Atim _ ,-v 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 laver: 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.): PRIv/—(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.): 9 Page 10 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address:. woow Owner. tl'l*,A� Date of s e tion: �s,j00 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:., (U f i. i 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertLoe dress: G'Lel►° Owner: Date of t on: ,�Uc SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to around water g 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 water elevation: 11 Permit Number: _ Dale. Completed by: :HIGH GROUND-WATER LEVEL COMPU T A T�lON Site Location: n, Lot No. Owner: Address: y Contractor:—,l�/�f � --Y Address: rotes: �2f5��'�S it S T EP 1 Measure depth to Water table jto nearest 1/10 3 Date �6-- o month/day/year STEP 2 Using Water-Level Range Zone j and-index Weli'Map locate I site artd determine: A 'Appropriate index I UWater-level range zone ......... STEP. 3 Using monthly report "Current l Wa-ar Resources Conditions" determine current depth to water level for index well • month I � /Year CT`' "— Using Table of Wates-leveld� _tments A =� I for index well (STEP 2 A), current depth to water level for index.well (STEP 3)., 'and water-level'zone (STEP 2B) determine water-level adjustment•........................... l _ I 'S T EP 5 . Estimate depth to high'water by subtracting the water- 'level adjustment (STEP 4) l from~measured*de'pth to water level a site (STEP 1) .:....... i� Figure 13.--Reprciucible cmno;.iaiioli icrn. F i I • 1 r CERT s . CA Off' ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared"For: Report Dated:- 03/22/2002 Order Number:- G0213729= Jeffrey Curtis: P O Box_ 1084' Marston Mills; MA. 02648 .Laboratory ID#: 0213729-01 Description: Water-Drinking Water Sample#: 13729 Sampline Location: 515'Wakeby,Marstons Mills Collected-.' 03/18/2002: Collected'by: Jeffrey Curtis 28=50 Received 03/18/200Z Routine ITEM RESULT UNITS MCL Method#k Tested-. ' LAB::.IC'L"ab Nitrates= .0.2 mg/L 10 EPA 300.0 03/19/20021 L4B:Metals- Copper • <0.1 mg/L 1.3 SM.311113 03/19/2002: Iron <0,1 mg/L 0.3 SM 3111B 03/19/2002; a., Sodium 10 mg/L. 20 SM.3111B .03/19/20O.T- LAB°Microbiology TotaMbliform; Absent P/A_ Absent. P/A 03/18/2001 i LAB::Physical:Chemistry Conductance- 81 umohs/cm EPA 120.1 03/19/2002' PH 5.7 pH-units EPA 150.1' 03/19/20OZ Note: Water sample meets the recommended`limits for drinking water of all above tested parameters.. Approved'By:: e- - -- (Lab Director) 3 �i•r.� co2 Superior Court:House;. PO Boa 427,. Barnstable,.MA. 02630 Ph:.508=375=6605 TOWN OF BARNSTABLE LOCATION 4fWe01 Y 40 SEWAGE # l c�/g::;l�� VILLAGE AW,'52'edI5 Al ASSESSOR'S MAP & LOT07-9—e-5-0 INSTALLER'S NAME&PHONE NO. � � � SEPTIC TANK CAPACITY /f®/v Ga L LEACHING FACII.TTY: (type) (size) /a ;Jf •,13' NO.OF BEDROOMS_. BUILDER OR WNER PERMIIDATE: COMPLIANCE DATE: � Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility St 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 r V 3a' No. �tV V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppricatton for Migonl *p5tem Conotruction Verrait Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) LJ Complete System ❑Individual Components Location Address or Lot No5- I' Ale,�w>11,,Oel, Owner's Name,Address and Tel.No. Assessor's Map/Parcel AW'S 7V 03 (IM3 �� Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(Ally Other Type of Building �'�@ No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3.3®O gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /15 lea Type of S.A.S. -r rff�¢ rS e � � Description of Soil lax 5elr Z t; J Nature of Repairs or Alterations(Answer when applipble) L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this and Health. - � Sign Date Z_/ Q Application Approved by Date Application Disapproved for the following rea n Permit No: Date IssuedC �0,�IVY ---- ------------ --------- --- -- Fee 0 No. !� - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes M PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 2pplicatton for Zigaal *pztem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) LJ Complete System ❑Individual Components Location Address'or Lot No. Owner's Name,Address and Tel.No. W s /Sr ?iW y/ To�� C'c ram/, S Assessor's Map/Parcel �yws 1D11j� /�/1//5 6—/�- ��eel iy ral Installer's Name,Address,and Tel.No. /" / Designer's Name,Address and Tel.No. Bot to Go��' Cor�s� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(XIT-1 Other Type of Building RPrI/'� No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow N `4�1 gallons per day. Calculated daily flow 3.3 6 _ gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I s—elo Type of S.A.S. Description of Soil '/OX ✓, Z 477-7 /e Nature of Repairs or Alterations(Answer-when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. / D Signe _ Date Application Approved byUYQL�� Date Application Disapproved for the following rea n Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS 02-6- BARNSTABLE, MASSACHUSETTS certificate of (Compliance IS TO CEPTIFY, that the On-site ewage Disposal System Constructed( )Repaired( ✓)Upgraded( ) Abandoned( )byor�CD 1��i1cST at r/JT AV as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '�' dated'77 1 1 Installer �--; ! �a I i Designer `s ?ti'' : .a.�Af The issuance of this permi/t o a'l% t be construed as a guarantee that the system wr �unction as designedDate `� Inspector No. �`I ` Z, 0 ' '5 _—_Fee 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Zigooar *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( 4pgrade( )Abandon( ) System located at 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:Construct1/2P�l d within three years of the date of thi? ermit.. Date: Approved by TOWN OF BARNSTABLE LOCATION �F—i;`j y ly� SEWAGE # l qlG 4'3 VU-LAGE / W-'5IhW Ai`15 ASSESSOR'S MAP & LOTOZ�'D-�� i INSTALLER'S NAME&PHONE NO. 1"6W e! JOy `. SEPTIC TANK CAPACITY i LEACHING FACILITY: (type)_i w'f��/,&,�r.,� �y� (size) /O i17s ,t ' j NO.OF BEDROOMS_��_ BUILDER OR WN R Lc�r f PERMTTDATE: COMPLIANCE DATE: r I Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /5 f Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by n4 I 00 i 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) I, ��l �/ "J_ ®/'��v /^ , hereby certify that the application for disposal works construction permit signed by me dated 7,!//11Q.14 , concerning the property located at cSISs �i� y/� �/a�0/i'� --'04/meets all of the following criteria: 6/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ere are no wetlands within 100 feet of the proposed septic system here are no private wells within 150 feet of the proposed septic system /TThere is no increase in flow and/or change in use proposed There are no variances requested or 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: r— A) Top of Ground Surface Elevation(using GIS information) U /• J B y 3 Z = y 5"Groundwater Table Elevation max.adjusted g.w. �- ��// , DIFFERENCE "l� , 7 SIGNED : i� DATE: Y [Sketch proposed plan of system on back]. h a zk ;r q heft folder•.oat ,F x ; � ,I� 000 Jy Q AOL i ( 3° 4 3