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HomeMy WebLinkAbout0079 HARRISON ROAD - Health 79 HARRISON RD., CENTERVILLE A= ��CYCtFp i UPC 1 34 • • ' WIST►IlOii IIN I 0 k No. Fee tv •THE COMMONWEALTH OF MASSACHUSETTS Entered in comp PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYtcatton for Mt5pont *pgtem Con5tructton Vermtt Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components 7 9 lion Address or Lot n ss and Tel.No. Harrison Rd , Centerville e I`� Assessor'sMap/P�cel 40 Liberty Pole , Hingham, MA 02043 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable) Install a new Title-5 tank and. D-box to be connected. into leach pit . (existing) 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 ear f Health. Si ned �v I, 9 ray g Date a� Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued r TOWN OF BARNSTABLE.._._ ,_ �.. z✓ . LOCATION 7 144 i5,Q J e.QAD SEWAGE # 2 o VILLAG ASSESSOR'S-1v1AP,& LOT �11 ?- t>Z 9 . J INSTALLER'S NAME&PHONE NO.R �',Nsok .SC12- 1L 7'75•-MG SEPTIC_TANK CAPACITY . 1500 LEACHING FACILITY: (type) ` JI' (size) NO.OF BEDROOMS 132 BUILDER OR OWNER PERMUDATE: i/25 ir2600 COMPLIANCE DATE: al c3o© � o Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well 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 Famished by u Ja No. eg4O4 4!�f �V � "� Fee n 50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2pplicatiou for Migo!6ar *p! tem Cowaructiou Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ' ❑Individual Components ` at Address or Lot ss and Tel.No. 0o 'f'arrisonN§'d. , Centerville " C a" Assessor'sMap/P ce1 40 Liberty Pole, Hingham, MA 02043 s4 G Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand .� Nature of Repairs or Alterations(Answer when applicable) Install a new Title-5 tank / and D-box to be connected�'Anto leach pit . (existing) s 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 ar of Health. > �� Signed � Date/ ,� Application Approved b Date -4�AWrS Application Disapproved for the following reasons L Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Hern BARNSTABLE, MASSACHUSETTS vis�orn Certificate of Compliance THIS RTIFY, that theOn-site SewageDisposal System Constructed( )Repaired(X )UpgradedAbandoned( m. E . Robinson Septic Service at 7 Ha Rd . , Centerville has been constructed in accordance i a with the provisi. s o Ttle 5 and the for Disposal System Construction Permi �7 dated Installer W • Robinson S r. Designer The issuance o/l'his .ermit shall not be construed as a guarantee that the system w' function as designed. Date / - 7 - Inspector ---- .---p------------------------------- 17 No./Lmay C/1/�tS� ee 5.0 IE CO�Mo.wE`A�LTH,�QE-MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS xern Mitpozar *pgtem Cougtructiou Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 79 Harrison Rd . , Centerville 7 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 -b^e completed within three years of the date of tthiss armit. Date: �r"' e� 7 '" � Approved bye 1����i ��� µ {r • 116/99 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 Will Tarn E . Robinson,S Thereby certify that the application for disposal works construction permit signed by me dated `-'d� �c �`'�� , concerning the property located at 79 Ha rr i g n n meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business V42aire ated with the dwelling. classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. no wetlands within 100 feet of the proposed septic system — P no private wells within 150 feet of the proposed septic system increase in flow and/or change in use proposed a no variances requested or needed. Yom of the proposed leaching facility will not be located less than five feet above the m adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor when applicable) .A.S.Nvill 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: A) Top of Ground Surface Elevation(using G1S information) B) G.W.Elevation _ +the MAX. High G.W. Adjustment .___,. DIFFERENCE BETWEEN A and B SIGNED : i DATE: [Sketch proposed plan of system on back). y:health folder:cen �. � t U�" y �- J �2� �- � TOWN OF BARNSTABLE_ %- LOCATION SEWAGE # ;i oc 34 VILLAGE_CCU Oi t c— ASSESSOR'S-MAP &LOT INSTALLER'S NAME&PHONE NO. RQ i-iwSo'J 5cp�r cL 7? —577� SEPTIC.TANK CAPACITY 1,5 OCR LEACHING FACILITY: (type) G. ' CJi T- (size) NO.OF BEDROOMS BUILDER OR OWNER PERMPTDATE: P/25 jc,2600 COMPLIANCE DATE: a1! 7 &o0o 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 Famished by ,Iq T T_ T. f•Jjv CUB i CO.KMONIVEALTH OF MASSACHL;SETTS _ ExECL;TIVE OFFICE OF EN-WRONMENTAL AFF.-URS :F DEPARTMENT OF ENVIRONMENTAL PROTECTION O\E WINTER STREET. BOSTOK I►L�0210c 161:j 292-550v TRL DY COXE Secretan ARGEO PALL CELLLCCI D VID B STR'-*HS Governor Cotnmissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Address: Pater Hern Property 79 Harr SO d.., Name of Owner G e ROv l l le Address of Owner: ,� Pole 141 ng am, MA Date of Inspection:,X-7—AO46 0 02�'I Name of Inspector:(Please Print)Wm. E.. Robinson S r. I am a DEP approved system!inspector ant to Section 15.340 of Trtle 5 1310 CMR 15.000) rn CopanyName: Wm. E . Robinson Septic Service MaHingAddress: PO Box 10 9, Centerville . iVLA Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this.addrFss and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training arld experience in the proper function and maintenance of on-site sewage disposal systems. The system: sew Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: A 0/ ��7 Date: O` The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (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 original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS v a �000 r i M FR tw_ OT rep,.-iSeO 9/2/98 Page IofII ' 1, • ... ro1 nn per....rA D...... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 4op"AddfeSs: 79 Harrison Rd.. , Centerville Df Daatete o of Ire pe �t e r H e rn ' INSPECTIO SUMMARY: CheckO8, C, or D: A. SY TERA PASSES: Itow not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon c pletion of the replacement or repair, as approved by the Board of Health,will pass. Indicate yes, o, or not determined(Y. N. or ND). Describe basis of determination in all instances. If "not determined',explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets) are replaced obstruction is removed distribution box is levelled or replaced ri The system required pumping more than four times a year due to broken or obstna6l4dIO. , Wft�.:T caa/3t!!n ylrjp piss' inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed revised 9/2/98 Page 2of11 X SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 79 Harrison Rd.. , Centerville , MA Owner: Peter Hern Date of Inspection: C. FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pub c health, safety and the environment. 1) SYS WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS N T FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 21 )YSEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the„$AS(s,Wjthin 0•feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) THER r revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART A CERTIFICATION (continued) Property A e s: 79 Harrison Rd.. , Centerville , NIA ' Owe: re er Hern Date of Inspection: D. SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. r or ondin of effluent to the surface of the round or surface waters due to an overloaded or clogged SAS or Discharge p g 9 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the 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: You must in icate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: e system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public ealth and safety and the environment because one or more of the following conditions exist: 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) The ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office f the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST Prop"Address: 79 Harrison Rd.. , . Centerville , MA Owner: Peter Hern Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least 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 examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. (J _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected 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 on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) '- 115.302(3)(b)] _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintananca�f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; PART C SYSTEM INFORMATION 'rop"Address: 79 Harrison Rd.. , Centerville , MA Owner: Peter 1jern Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:6eyZ(�g.p.d./bedroom. Number of bedrooms(dlesign):- Number of bedrooms(actual) Total DESIGN flow Number of current residents Garbage grinder lyes or no):_d Laundry(separate system) (yes or no)k 0 If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): /L v 1998 33 , 000 gal. Water meter readings, if available (last two year's usage(gpd): Sump Pump(yes or no):/V O 1.997 87, 900 gal. Last date of occupancy:2L-2nAo-G COMME CIAL/INDUSTRIAL: Type of a tablishment: Design flo god ( Based on 15.203) Basis of de ign flow Grease trap present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non•sanita waste discharged to the Title 5 system: (yes or no)_ Water met r readings,if available: Last date f occupancy: OTHER: escribe) Last dot occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System umped as part of inspection: (yes or no)Lli 0 If yes, volume pumped: /b gallons Reason for pumping: L,1o/b L % jo{J y`fN TYPE OF YSTEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known) and source of information:/L� A-1111 - r ".tc, 4-, Sewage odors detected when arriving at the site: (yes or no) /f-v revised 9/2/98 Page 6of11 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eorttinued) trop"Address: 79 Harrison lid.. , Centerville , MA Owner: Peter Hern Date of Inspection: BUILD G'SEWER: (Locate n site plan) Depth bel w grade:_ Material construction:_cast iron_40 PVC_ other (explain) Distant from private water supply well or suction line Diame Commen s: lcondition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grade:-20' Material of construction: t/concrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ Wage confirmed by Certificate of Compliance_ (Yes/No) Dimensions:-, 4G l 0 -L Sludge depth: r Distance from top of sludge to bottom of outlet tee or.baffle:144.1 Scum thickness: 0 1 r Distance from top of scum to top of outlet tee or baffle: J ' Distance from bottom of scum to bottom of outlet tee or baffle: +✓� How dimensions were determined: ,4.i I✓��'!il� ;omments: (recommendation for pumping, condition of inlet and gWlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of lea age, etc.) A-J �� 1 . If r AAFi- 6A S A0,0/- L` "Z. b C GREJ E TRAP: (locate n site plan) Depth bel w grade:_ Material o construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimension Scum thic ness: Distance f om top of scum to top of outlet tee or baffle: Distance rom bottom of scum to bottom of outlet tee or baffle: Date of I st pumping: Comm nts: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid a of leakage,etc.) I I revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"address: 79 Harrison Rd.. , C ent ervmlle , MA ° Owner: Peter Hern Date of Inspection: _2_,7c-t+ ,.w TIGH R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate o site plan) Depth bel w grade:_ Material construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi s: Capacit gallons Desig ow: gallons/day Alar present Alar level: Alarm in working order: Yes_ No_ Date o previous pumping: Comm ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and dis ibution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUM)on MBER: (locate plan) Pumorking order: (Yes or No)Alarorking order(Yes or No) Com(noteion of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address:79 Harrison Rd . , Centerville , MA Owner: Peter Hern Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): 4.11 (locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number: leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, si ns of h draulic failure, level of onding, damp sail, condi 'on of vegetation, etc.l `tea ' T ' ,a �% 1 d S �h ti a:. = e.41 CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comme s: (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth o solids: Comm ts: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) ",rop"Address: 79 Harrison Rd . , Centerville , W' Jwner: Peter Hern Date of Inspection:2 7—� a-U-6 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) f I 57d U t 1 r bo h i 6 I . i revised 9/2/98 Pagc10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cort6nued) rop"Address: 79 Harrison Rd.. , Centerville , MA Owner: Peter Hern Date of Inspection:,2 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwatery Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record V Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 102 IAI� Is Xd �- Lois IJa w revised 9/2/98 page 11of11