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HomeMy WebLinkAbout0530 WAKEBY ROAD - Health 530 Wakeby Road, Marstons Mills A= 028 -026 y ` � 1 i I f TOWN OF BARNSTABLEv/ OCATIOrf— � SEWAGE # oaf VILLAGE ��IT. Ag.S�SE, &��- T SSOR'S MAP &fL/OT a -T�P�70,?dkN[E&PHONE NO.nn4P 6 p�i:�42 SEPTIC TANK CAPACITY/0-0 LEACHING FACILITY: (type) Q (size) )O oe NO.OF BEDROO ��Od U 6 �C� BUILDER O OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t3 r to 9 O't . - ej�.G2P'i` t� -- TOWN OF B�AR�NSTABLE ) LOCATION � "�"-= ' SEWAGE # VILLAGES, �,'( S ASSESSOR'S MAP 6 LOT 44 I� INSTALLER'S NAME & PHONE NO.Tdo r ` �uja, �10� SEPTIC TANK CAPACITY OOc� LEACHING.FACILITY:(type) ` (size) T NO. OF BEDROOMS—PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER anA 0 I DATE PERMIT ISSUED: , DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No W'�11 ICOO �.—.— ioo� 1�Y Afi '� DO i No. ._... L©T THE COMM NWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ,. ..4...... A................oF...... .............. Cc,_ -------- ..................... Appliration for Disposal or�s Tonotrurtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - -- ` - - .-. `a � ....... .. c?. : o r Lot No. � ..................... Lation-Address ----------- ------------------------- ........ ........................ Owner e- ^,-n Address w ... .......... � .. Installer Address U Type of Budding yhtVhd Size Lot--- Dwelling—No. of Bedrooms.....s .................................Expansion Attic (Acp Garbage Grinder ( ) 'PL4_l Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures .........:....•---•--__.. w Design Flow.............5.6.._.._.._..........__gallons per person per day. Total daily flow__-_33.Q_...._........._.._._....gallons. WSeptic Tank—Liquid capacity.l�gallons Length_(S1f_ .. Width._s 7.1=_ 'Diameter............... DepthA�-.6_ f x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........I.......... Diameter........S-....... Depth below inlet.....G.......... Total leaching area..................sq. ft. Z Other Distribution box (Y,!!Y5 Doslu t nk (QC> CO '-' Percolation Test Results Performed by. ). ..8.7..--...-_.... P4 Test Pit No. 1....L-Z.----minutes per inch Depth of Test Pit-----C.�........ Depth to ground water..9 Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground ti water______-_--_--_---_--____ -------- ------------------------------------•----------------- --•-C ------------------------------ Description oo .... t-^ b PSUKeL x V ..................... ------•----------------------------------------- .......--------------------------------------------------------------------------- •------------------ •--------------- •------------•-------------•----------••------------------------------------------•-------------------•------------•--•------.....-•---.....---•----...-•-----------------------•-•--------............. U Nature of Repairs or Alterations—Answer when applicable................CLA--- ._._. -_----__-_--------------••------•-- f ---•---•---•--------•-•----••••.....••--•••--••-•-----•---...---•••--•••--•......................••---•-•-••---•••-------------•-•--...•••...........--- .............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Se isposal System in accordance with the provisions of TIT!.- 5 of the State Sanitary Code— The undersi ed furd r agrees not to place the s ste in operation until a Certificate of Compliance has been i d the bo d.o h Signe -- Date Application Approved By.............. -- - ...�........ ........ ' Date Application Disapproved for the following reasons:............................................................................................................ ......................................................•--•-------•------------•-----••------•----•-----•--•••--•••---•------•---......-•---•••....--•---------••-•---••••--•-•-••._.........--•--•----- Date Permit No...... _..._.... . --------------- Issued. ............. p, Date r � v FEs.....-. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. J� 1�.1, OF....�. �t?=.:� :�z'i? i t 1.................................... Applir a#ion for Disposal Works Toustratrtiun Prrnti# Application is hereby made for a Permit to Construct ( ;>U or Repair ( ) an Individual Sewage Disposal System at: k D`. 0.^. �,t i3�; ! ,:7t t t2.5 ��`.s 5 � vC 5 .....................•--- • _................. -..... -•---........... --•-•-----...----------...Location- or- `� ! �... ` ,f .I Lot No. � p �q r Address _ Address Type of Building _ � Installer `c '�0•�� (.(( � d n^ (/th'/� Size Lot.._k.: ..`� .. U Dwelling—No. of Bedrooms._.. .................................Expansion Attic (�� Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtuies ----•---------------------------------------- --•-•----------••--------------------------•---••------- W Design Flow............. ......................gallons per person per day. Total daily flow....7.�. .........................gallons. WSeptic Tank—Liquid*capacity}:>__ gallons Length. (__-G.. Width.__�-_,E5 Diameter---------------- Depth:-.5. .-_a... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........[.......... Diameter.......-........ Depth below inlet.....Ll........... Total leaching area..................sq. ft. Other Distribution box Dosipg tp 00 T'vt,_t, it=.w�i e<< _C�=-r s _ '-' Percolation Test Results Performed by. :�:_!_4 �SS`4 _ _�► . Date...�o:z ...E-7----- _---.. ,aa Test Pit No. I...�. .._.minutes per inch Depth of Test Pit_.I.(l........ Depth to ground water_.E�p:f'.k�1t���a ei�"sc<Gt) Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ..............- t______________________________________________________R___._,___....Y..=........h.__........._....._....`..............................___. QQ .C.;,.,n... '.',..:k>h ..:, _ (.,_ • 'r .. Description of Soil.... --=-'------•---.....----•-•---•-----------•----•----•-•-----•---------•--•-----------•----•-•-----•---------•---------•-'=.................................. 0 ------ ------------------------------------------------ ----------- ---------------------------------------------------------- •---------------------- -------------- ------•-------------•---•-------- W ----------------------------------------•--•----•-------------------------------------------------------•-----------------------------------------------------•----•----------...............---------•- UNature of Repairs or Alterations—Answer when applicable................_.. __.. o, ----------_--------------------------. --------------------------------•--.........------------....._..........--••------...........----•---•--•-••-•-----------------........----•-••-------•--------.....--------...--------....--•--.••--•- Agreement: The undersigned agrees to install the aforedescribed Individual Se Disposal System in accordance with the provisions of TITLi� 5 of the State Sanitary Cod The undersi ed furt er agrees not to place the s stem in operation until a Certificate of Compliance has been ' ed y the bo d o h Sign .... ••------. --- .... .. .......••• .... .... ...... /s�•- Date Application Approved By........... �..: ...... -- 65 Date Application Disapproved for the following reasons:.......................... I..� Date Permit No..... = - 'c/---- _.._ Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /� ifs -a.............OF........ r.�c^-<<� t�YX ................................ Tnrtifiratr of fananpliFanrr THIS IS TO CERTIFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired by---------------------t_,r .i �=e.....-- •.ft •-••...-•--•-••--•-------•-----••••................•--••... -•--•---••-._...•-•--•-----•.................................... Installer at................ ---.....wa - ....-----1-)�---------•---•-• 1 ,t�'j• %----------------•-------•-----•---•-•------------------------ has been installed in accordance with the ovisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......9..&=....L;.L.�__.... dated..............................................� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF (MASSACHUSETTS BOARD OF HEALTH ` ...........................................OF..................................................................................... No.1?6. .. Disposal Works Tonsiturtion Vvrrmit Permission is hereby granted....... - 4-e4.....to Construct or Repair ( ) an dividual SPwa" ge Disposal System at No. .. ..Q !?. qVorks ..-- .................. l t�,� iPf.� Street as shown on the application for Disposa Construction Permit N�P.a Dated ............................. r -; - : ........................of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS x x e st.. - R��-saM� i�r,,.�„� -x..� ��,'-,.. s,. use 5- , y 'a �.,;$ �R •i � ���, ��,; rc �. T � '� � � ,�a . .rw+.�t,�y q� n � ���,,,,. �a F it "? r �+�, �i� > �.��,$ r4 ry,f c,- �. �i+�•�r i �r"S�'1 ''i, �� C`t ' g�P�� +l ��i6 s +"".'`� TM�"•y"7���/,,�1 � {i�y"�,`� F-Nnv�. `� "• ::z d� k'� �§%'`��' .� ��..,,�� � + r r� BORTOLOTTI CONSTRUCTION,INC. �, l°ti�oF 0 765 WAKEBY ROAD,MARSTONS MILLS,MA 026 508-771-9399 508-428-8926 FAX: 508 428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION]NORM J PART A L:� r / ' CERTIFICATION Property Address:, & W LIL'� v-A Date of Inspection: D1 z7 In tor's ame: sqQj6&Z�_ er's Name and Address: CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal s/y ems. The System: V Passes Conditionally Passes Needs Further uation B the ocal Aproving Authority Fails Inspector's Signature: v - Date: The System Inspector shall sub a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The origisral should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY! A)SYVM PASSES: I .i have not found any information which indicates thl m the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure:criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system-components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describc Wis o'determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structural'a unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. Tire system wilii pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - ,Say s71. a' kr "tt vyterJl;v' , a 1,` Kr• + ,tr a # "! way;- 7ry x�t--7 l by ` 1 YL . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced. The System required pumping more than four 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 Obstruction is removed 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF.HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND.THE, ENVIRONMENT: :The system:has aseptic tank and soil;absorption system and is within l00 Feet,to a surface.: ' - water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. is tank an d soil absorption stem and is within 50 Feet of a private, The system has a Sept rp system water supply well.. em and is less than 100 Feet but The system has a septic tank and soil absorption syst r Feet or more from a private water supply well,unless a well water analysis for coliform 1 bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the-presence of ammonia nitrogen and nitrate nitrogen is.equal to or less than 5 ppm: D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below.�The.Board.of Health,, should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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,t an,overloaded or clog- .,:ged SAS or cesspool Liquid, . P� uid depth in cesspool is lessthan 6 below,invert or available.volume is leis than 1/2 P day flow. " Required pumping more than 4 times in.,the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- ti.`.e., a --v � ,+,. ar.� ,: -,,:»a*s.: .•.:ae,u� ,i _ �"s+'K�..�� r 4 x it i, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 Il of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local: regional office of the Department for further information. SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ►/Pumping information was requested of the owner,occaipant,and Board of Health. _VNone of the system components have been pumped for atleast two weeks and the system has, been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _As-built plans have been obtained and exandned. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _L/The system does not receive non-sanitary or industrial waste flow. __ 'The site was inspected for signs of breakout. ; _L/All system components,excluding the Soil Absorption System,have been located on site.k �fhe septic tank manholes were uncovered,opened,and.the interior of the septic tank was in- spected"for'condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System ou the site has been determined based on existing information or approximated by non-intrusive rnethods. 3- r W, st i _5•n wa MIN � � �'r �7 '� -�yr^ �' �� �' n '�'" ,,rt•{,,�bk' r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) ✓The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION_ FORM PART C SYSTEM INFORMATION } FLOW CONDITIONS Design Flow: 3v allons Number of Bedrooms: 3 Number of Current Res %nLsz)�,e �Garbage Grinder: Laundry Connected To SystemG'� Seasonal Use Water Meter Rea gs,if v ilable: Last Date'of Occupancy: COMMERCLAIAINDUSTRIAL:k)(). Type of Establishment: Design Flow: fallons/day Grease Trap Present: (.yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS.and source:of informati n:: System Pumped as part of inspection: t-v If yes,vie pumped: gallons Reason for pumping: TYPE OF SYSTEM: `Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(I s,attach previous inspect' records,if an Oth r explain): sal APPROXEVIATE AGE of all componen ,date installed(if kno n) d,source,of,-infor ation: .� �... . _ - Sewage odors de ted when arrivi gat the site: -4- k" , �X Y3'.yi .✓ Y ne^_,�7. �y .r. t'�Y�,�'� ��xd� .,c.F°y .:'.._� ,...�y .n, 'aRt t-`,�. kt .. :� . 1 •,:rs 'cra!�t c,„,ao Yc „� .;�p,,Y U }.fio "'�`'-, - '��"f�P.. '.► �'�' `ayy'�"s,�'' ,.i'k`'stt -�s"7`�, "�.5s'`.�.���.�ih''..5 ✓y;u."s � '�:€�t,�'a`.c 1 ,,;+ •*'Syr�s ?t a. ra %�•s'a F {sr. 'syi• " a--j w `- " *.. .rid k d. 'a{,°y.;,:> s. c�' L r�ec"3�{'i`''.t13•.`«i`*3s*"., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: 49 Material of Construction: ✓concrete metal FRP Other (explain) Dimisions: ' -' Sludge Depth: / Scum m Thickness: Distance fro top of sludge to bottom of outlet tee or baffle: • 3 7 // , Distance from bottom of scum to bottom of outlet tee or baffle: If/ylle Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid 1 el in lation tM,utlet invert, structural integrity,evidence of leakage, tc.) /000 v GREASE TRAP:_ Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: , _ .._..Comments; (recommendation for pumping,,condition of inlet and outlet tees or baffles,depth of-liquid level in relation to outlet invert,structural integrity,evidence of-leakage,etc.) TIGHT OR HOLDING TANK: l�D Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: gallonstday Alarm Level: Comments: (condition-of inlet tee,condition of alarm and float.switches, etc.) - • ' DISTRIBUTION BOX: Depth of liquid level above outlet invert: 1 Comments: (note ir�'�j eland distributio is equal,eviderte6 o�solids carryover,evidence of leakag into or out of x,etc.) ,mf ��� _-�� � PUMP,CHAMBERS ✓ , Pump is in working order: _ Comments: (note condition of pump chamber, ndition of pumps and appurtenances,etc.) 7- -5- '••St.. �� _ 3 h `�RT..1#�+G +� 3S tivl C ,t.. .. .}N3 -"b! x 1 `k +_F� /i" 1'w$.-alp, ' a.$ +� ;E�k "i`� �`°. �l atla' 1'� �sY ��edp j��th f.3.}N '7c '_:Y ai'q•tf`ii '+{ ,�'+. "�r"x��A ! ti � a � a B '4 ' �� Tyf�'�.aa�i�dYl ✓�L,4 t �-z� '3`� � T s*'P Y SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):J� (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comm nts: (note condition of soil, si ns of by aulic f ' ure level f ponding,condition of vegetation, e 00 CESSPOOLS:do 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) °t -6 - ..'« r Y -1''.`c�� S°'f'Fr:''*,r�- �#!r �4a?4'a�s. r �. Efr+t�+�- `$•?^`.7 sue'°' 'f '"#r., r41}v':k�..,,.r ,g+ �};:��`�� i".vxii^�,���"� 'Nr.' +. � :�Sf •#`Y�Y '3 ; � dE>o-: ! ram'f' -:h��r���r'�{�;4;, w.+e'�i"€'`�yN�s ,ytfk5'��°P'"• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. y (c _ �q r. DEPTH TO GROUNDWATER: / Depth to groundwater: Feet Method of Determination or Approxima 'on: /I� l&X/� ,,+, -7- a f TOWN OF BARNSTABLE i3OCATION-;� Roaw SEWAGE # . �' � / Oaf VII LAGS/`t ASSESSOR'S MAP &�L/OT 9 . IgPCr1-0,fS A,/A-iE&PHONE NO.-- -- - - 21 &-Yal SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ��c' C./) (size) A OC) NO, OF BEDROO 40d BUILDER O OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by v� (a O oy p P f Cvcc�,R�onS i i t - ' i ' s TOWN OF BARNSTABLE �(�+-+� - ' SEWAGE IDS LOCATION VILLAGE 11 I S ASSESSOR'S MAP & LOT ' INSTALLER'S NAME & PHONE NO. I SEPTIC TANK CAPACITY 40C) DQLA4 , LEACHING FACILITY:(type) '• NO. OF BEDROOMS _PRIVY_WL OR PUBLIC WATER BUILDER OR OWNER V1{1 40.0 A > DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: `VA.RIANCE GRANTED: Yes No Y a" we fi 4 � .- 'Fro it-A i �_ 1, �u,� ��Nt�% l� tZ.�C3?�?4tZ�•.#�' .�V M.� �t1/�(,..�.: `�C C At^r�t��.x:, fir• 1�f4�S l?+�C�[ 1�11r�,�L�.�� , r l Q'V S, 'Z) ate, �GJV�r'�'�"S� \"M- A-nJ ALA,-KK eY AcSG? Jar G Gt9.1-lu Li G� FROM Postip Ftw_ur e V j )bd ST { i t,e. t �,-c f' #.LY r,_@ ti tics J ?�� r S � S,.. jo?l s �t Df�_2s►Gq LATA J PARG'f� L 3 3 3E..plZoc�lv�5, N0 GA��A6�. C��iND�R PARCEL �. �1T�� I�I It� L®1clE,� t_EV�L � h10 �3fi,TNROGN�cj ►N I t AcF,E-54-1 Low-1ER i-�vt✓L 11D3r-,v k 3 BR s 3 0 GPp Ex�STiN� � F-I-1C. 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