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Home My WebLink About0087 HUCKLEBERRY LANE - Health 87 .Huckleberry Lane Marstons Mills P A = 102 130 ,1 lo Commonwealth of Massachusetts a"/3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /87 Huckleberry Ln 3>Marstons Mills, MA 02648 ✓ � Property Address N3 Carl Thut owner owners Nameinformation requhad for� Yamtouthport MA 02675 1/11/2017 Page- Cityrrown State Zip Code Dale of kgXKtion �a Inspection results must be submitted on this fonn.Inspection forms may not be altered in any way.Please see completeness checidist at the end of the form. firm A. General Information S/ / a 0 q�- on the computer. use only the tab 1. Inspector. key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services VQ Company Name 350 Main St Company Address as W.Yarmouth MA 02673 Cityrrown State Zip Code 508-775-2825 S15016 Teleptw w Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Peres ❑ Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority 1I16=17 nspectors Sgnawre 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. *: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. t5ets•3H3 rft S of6al t►spedion Fame Sdxufaoe Sewage Disposal System•Page 1 of 17 �O ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Huckleberry Ln Marstons Mills MA 02648 Property Address Carl Thut Owner Owner's Name information is required for every Yarmouthport MA 02675 1/11/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Huckleberry Ln Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is required for every Yarmouthport MA 02675 1/11/2017 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain.below): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 87 Huckleber Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is Yarmouthport MA 02675 1/11/2017 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cont.). 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 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. ❑ 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 water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal colifotm bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•all Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Huckleber Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is Yarmouthport MA 02675 1/11/2017 required for every State Zip Code Date of Inspection page Cityrrown B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any.portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply Q ❑ 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 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 87 Huckleberry Ln Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is MA 02675 1/11/2017 required for every Yarmouthport page. City/Town State Zip Code Date of Inspection C. Checklist 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? ® ❑ 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 NIA) ® ❑ 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? ® ❑ 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? ® El information 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 1.10x3= 330gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Huckleberry Ln Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is Yarmouthport MA 02675 1/11/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑. No Seasonaluse? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): 2015=85gpd2016=82gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 12/25/2016Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y` 87 Huckleberry Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is Yarmouthport MA 02675 1/11/2017 required for every Zip Code Date of Inspection page. Cityrrown State D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type 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)and a copy of latest inspection of the i/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� 87 Huckleberry Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is required for every Yarmouthport MA 02675 1/11/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1998 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 16„ Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Line checked witrh sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500Gal 4-6" Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s•'�e 87 Huckleberry Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is required for every Yarmouthport MA 02675 1/11/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 1-2" 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? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers 6" below grade. Grease Trap.(locate on site plan): Depth below grade: feet 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: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'t 87 Huckleberry Ln Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is MA 02675 1/11/2017 required for every Yarmouthport page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle.condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ .No Date of last pumping:. Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Huckleberry Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is Yarmouthport MA 02675 1/11/2017 required for every '6tyay own State Zip Code Date of Inspection page. D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Oil 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 leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure Cover 10"below grade. Pump Chamber(locate on site plan): Pumps in working order: - ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and.appurtenances, etc.): *if pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,.explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 87 Huckleberry Ln Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is required for every Yarmouthport MA 02675 1/11/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-500 Gal chambers with stone. 1"of effluent at time of inspection. No sign of overloading or hydraulic failure. Cover 11' below grade. 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 ❑ No t5ins-3/13 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 87 Huckleberry Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owners Name information is required for every Yarmouthport MA 02675 1/11/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont) " Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(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.): Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17, t5ins•3/13 Pe 9 P Y a9 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 87 Huckleber Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is Yarmouthport MA 02675 1/11/2017 required for every page City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 87 Huckleberry Ln Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is Yarmouthport MA 02675 1/11/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells +11, Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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: Hand auger to 11'with no water encountered. Bottom of leaching at 6'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 or 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y`a 87 Huckleberry Ln. Marstons Mills, MA 02648 Property Address Carl Thut Owner Owner's Name information is required for every Yarmouthport MA 02675 1/11/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN Ur BAKNSAAb" M.t, LOCATION &(/tkA-ReXX y LA SEWASE t. 97 30.5- VlILAGE ht fF RS fQA15, M/G LSASSESSOR'S MAP&LOT to I- Ur INSTALLER'S NAME&PHONE NO. J- Ad A C oAf/3 eR+ 5 O.y SEPTIC TANK CAPACn Y X SO O LEACHING FACILITY:(type) x Aea y e,*AA96 ew 3 (size) SOa G%1 4- NO.OF BEDROOMS Z BUILDER OR OWNER PERMIiDATE: 18^9'$ COMPLIANCE DATE: .5'— V Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Fee Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Fee, Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching facility) Fea Furnished by Ij . a ) h COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP 12' PARCEL ; 13 O LOT TITLE S OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ,L� CERTIFICATION Property Address: / 'W Glep erY' EW Owner'sName•Owner'sAddress• hc�,- G �i' L� 003 Date of Inspection: // ,to pSTABLE Name of Inspector. lease print) r Company Name: J1 i 0— T E Mailing Address• o o x /d EG -1 Dd Gu,Z Telephone Number rW 97,— CERTIFICATION STATEMENT I certify that I have personalty 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: y p Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 7 d 94, Inspector's Signature: a-a Date: // d 0 p 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 f gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A J CERTIFICATION (continued) Property Address: �� /7 vl c !6 bP01 Cal Gota� Owner: "xt N' Date of Inspection: p Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. $ 7 Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below._ _ Comments: 16L System Conditionally Passes: /1/ 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: i G e /' Z�ij/ Owner. W e/-" Date of Inspection: 141J.,oUZ C. Further Evaluation is Required by the Board of Health: /(,//Condi ions 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: _ 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. _ 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 water 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. r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 111.4C1,4 �er Z— /I/ Owner: Date of Inspection: / o D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes VNo/ _ kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool l/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ V'Liquid depth in cesspool is less than 0 below invert or available volume is less than%day flow �Regnired 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 c�Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ,Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified 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.] L2/ (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: Y To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 1pd. 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 y _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface ddnldng water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public water supply well If you 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CH_ CK LIST Property Address: fit c l/✓lC Zvr,r " �-� Owner: wA/� r /��'/ �� Date of Inspection: // VAzz Check if the following have been done.You must indicate`yes"or"no"as to each of the following ✓ 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 �;�7ft 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 Were all system components,excluding the SAS,located on site Were the septic tank manholes unc overeck opened,and the interior of the tank inspected for the:condition of the baffies or tees,material of constriction,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. Deternuned in the field(if any of the failure criteria related to Part C is at issue approximation of dis tance stance is unacceptable)PIG CMR 15.302(3)(b)} I Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: o L4 L/2 ,04� n .l��/!-4 pot Owner; l�✓o��v�'r Date of Inspection; // o 03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 13.203(for example: 110 gpd x#of bedrooms): ��b 9�— 305 Number of current residents:0 / Does residence have a garbage grinder(yes or no): 1f*'49 Says ,� ��olra�►s f Is laundry on a separate sewage system�es or no);j,0 [if yes separate inspection required] Laundry system inspected(Yes no):_° Seasonal use:(yes or no):L�4 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):/mod Last date of occupancy:�rci •,7 COMMRCIALA NDUSTRIAL Type of establishment: Design flow.(based on 310 C dR 15.203). Snd Basis of design flow(seats4=sons/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 INFORMATION Pumping Records 1 /1 Source of information: 1^7 ?v wj C9 r.., Was system pumped as part of the inspection(yes or no):o If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPW01 SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _ivy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _InnovativdAltemative 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):— I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Gtc 4,l 4e G- h •'� G 4Y Owner: d.- Date of Inspection: O BUILDING SEWER(locate on site plan) Depth below grade:�0 Materials of constnictiocti n: `—castiron _46PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_`f(locate on site plan) Depth below grade: Material of construction: concrete_metal fiberglass_polyethylene ^other(exphrin) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) ;x Dimensions: � Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 33 Scum thickness: G,f ff Distance from top of scum to top of outlet tee or bathe: Distance from bottom of scum to bottom I outlet tee or We: How were dimensions determined ro l 046 h c Comments(on pumping recommendations,inlet and outlet fee or bale condition,structural integrity,liquid levels as l✓`�f n /) ated to outlet im�ert,evi of lPeaka .): H O n GC G A�- f ch N �r- ' J. V. GREASE TRAPeO aeon 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Aa/SYSTEM INFORMATION(continued) Property Address: i"r, Owner: �+/a��tr- h ��/ ,� 6P tW Date of Inspection: d b TIGHT or HOLDING TANK: /(i (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: eallons Design Flow: eailons/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: I Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into�� out of box,ptc.): Y-0; is /eve/. l(/O ,S/,es Ay L.eg�f 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: O1 11�1��$ bey Owner: Date of Inspection: / O SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Typelawffin �- - ✓leachmg chambers,number. y2- leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Typethame of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, Q.a O'!n ga ✓/ f CESSPOOLS:e! (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.): s Page 10 of 11 P OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 . h ��//�6j pot Owner: We4l G✓ Date of Inspection: 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. P / 3 - 301 9i - 2Ir Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q� SYSTEM INFORMATION(continued) Property Address: U/ Aw`P- L y Owner. o� p �I Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water f-'C-Lfeet Please indicate.(cheek)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed 'ed site(abutting property/observation hole within 150 feet of SAS) !/Checkr.d with local Bard of Health-explain: -V4,2-o Checlwdwith local excavators,installers-(attach documentation) Accessed USES database-explain: �'d F You mn�g�ibe how you established the high ground water elevatio �fol5�pr, o 74 A�o�� a..� iio tir► wa r ��. T o P o f i- ,-* ale, a+S J ��'0 TOWN OF BARNSTABLE . LOCATION If7 AlucA% 13eXXV LA SEWAGE # Fg'r �OJ� Ii VILLAGE /14 A R-5 2'0,61-5 A4 /L L ASSESSOR'S MAP & LOT /62- I3 D INSTALLER'S NAME&PHONE NO. /b �4 A C ow/sex SEPTIC TANK CAPACITY /. J-0 0 LEACHING FACILITY: (type) %Z /�'Za4v elY1, 4,6 ex;; (size) 5-06 G 4 4- NO. OF BEDROOMS ; BUILDER OR OWNER f G.pp- PERMIT DATE: _� I g ,�S!COMPLIANCE DATE: 15-- I -�f V 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 I '•` �� ,� / F � � � � r,. i .�'� I-_:. No. �0 Fee s QB THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipptication for �Bigozal *potent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Addressor Lot No. T ! b�Ij, )W wr [" Owner's Name,Address and Tel.No. �32��J aw! ,aAx� Assessor's Map/Parcel /0 s`1 % �s 0 Installer's Name,Addre s,and Tel.No. ��' Des' ner's Name,Address and Tel.No.5'v$ '7�`� Z Zyi"corn J� ¢ L; � ,Q h� %ice 13a0e � % Type of Building- Dwelling ; No.of Bedrooms Lot Size sq. ft. Garbage Grinder(Aoo Other Type of Building _No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 110 gallons per day. Calculated daily flow -.5 le )? gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ///trA4 Type of S.A.S. - f--AD 5;J�YnkW223 Description of Soil A%A U;,1d �44J/J r.6 6kq-- 3��1� Nature of Re airs or Alterations(Answe 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 y this Boazd f H lth. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued =17_9 IF TOWN OF BARNSTABLE LOCATION-' I X/0 X 9 1✓ ZA SEWAGE # Y8- 3.UJ� VII.LAGE ^n ��-� ��s /I/f /LGS'ASSESSOR'S'MAP & LOT /61• 130 INSTALLER'S NAME&PHONE NO. /b ,t4 A C D Y LAI i SEPTIC:TANK CAPACITY s 4 LEACHING FACILITY: (type) x 04/ch,/f o6 err S (size) S"c>a G 4- NO.OF BEDROOMS :7, BUILDER:OR OWNER - — PERM_ITDATE: .,�^ 19 -3%_COMPLIANCE DATE: S'- Separauoa 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 sitp:o�within 200 feet of leaching facility) Feet Edge of-Wetland and Leaching Facility(If any wetlands exist w 300.feet of leaching facility) Feet Furnished:by Ilk i \ .yt 1 .� No. "30� Fee �(1s Q� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Lpplitation for � gpogal *pgtem Con!6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 57 &bWr,y )44,w Owner's Name,Address and Tel.No. Assessor's Map/Parcel S / Installer's Name,Address,and Tel.No. Des ner's Name,Address and.Tel.No. jQ)MM$jWrn bee_ r aver f Type of Building:�* Dwelling ; No.of Bedrooms Lot Size sq.ft. Garbage Grinder(Ao Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixture', Design Flow s 4, gallons per day. Calculated daily flow 1e )l a .gallons. Plan Date * . Number of sheets Revision Date �a Title Size of Septic Tank /J"Pd Type of S.A.S. _ Description of Soil UAO ,14 noel Z-6 6ky 4e 3)4/1.�_d - i Nature oflRepairs or Alterations(Answer when applicable) JE"' 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 Boai•d f H lt:h��/ s Date �G_ ��•1�' Si ned '� Application Approved by Date :S -/W_-9� Application Disapproved for the,following reasons - Permit No. �7-.� Date Issued �i'17-119' IF THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by a,dP , 3- ,!"I at 9_ AZZ ZC& -7w�+V he i-6,00,y e �� ,/�' has been constructed i ae orda e with the provisio s of Title 5 and the for Disposal System Construction Permit No. l `3o S dated Installer I.: , ,ram I^ 2W. , Designer �9CC �luY� The issuance of this pe t s not construed as a guarantee that the system wil unct' n as designed. Date ' fl Inspector , ------------------------------ y No. 9 -3US Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lMigpogaf *pgtem (Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(A Abandon( ) System located at � � .11� A&X�,� ,4�,aa�,r � �r�rT ,• ,�,� ` and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: �' /�- /� Approved by 10/9/97 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 ENGINEERED PLANS) I,Joseph P Macomber jr- , hereby certify that the application for disposal works construction permit signed by me dated 5/18/98 , concerning the property erty located at meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will 114.t be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation (according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : r �� DATE : 5/18/98 LICE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert o k®ac