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Home My WebLink About0137 PRINCE HINCKLEY ROAD - Health 137 Prince Hinckley Road Centerville P A = 172 196 LOCATION SEWAGE PERMIT NO. If r�� i��du c� �i�✓�kc y R1� . 79— = VILLAGE I N S T A LLER'S - NAME & ADDRESS Cam/ l/ B U IL D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 3_ 7�- `r 1 � V1 �y s �\ � \// � ./ �� I 701, J No...................... Fizz =x................ THE COMMONWEALTH OF MASSACHUSETTS BOARD HE .................OF......... � .......... Appliration for Disposal Works Tonstrurtion rnmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal SysteT at- 10 t.. � ? -J.44, ............................................... .. ....... .. E'O'C"ion.Address for Lot N--.4- P............................ ............... 0%............. ............. fter Address .............. .&�....................................... ................... .......... ......... s 001:27............. .............. Type of Building In taller Address e� ii:::::;; Size Lot,..--s /-V Sq. feet .. ....-t...." Dwelling—No. of Bedrooms...............14-----------------------Expansion Attic Garbage V10 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ................................................................................................ Design Flow..__. 71r)........................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity gallons Length................ Width................ Diameter.........---.... Depth-............... Disposal Trench— 0. Width.................... Total Length.............._..... Total leaching area....................sq. ft. Seepage Pit No.......t0...;.TVD:1a...m"e*t e r.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box Dosing tank 7 7 Percolation Test Results Performed by... .......0.... .)C41a.e.4.......... Date... .......... Test Pit No. I----------------minutesperinch Depth of Test Pit....--............._ Depth to ground water.......------........--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit---............._... Depth to ground water........................ P4 ........... -----------------------7.... ...............................A..... 0 Description of Soil------. ............................. ........... e.d..... ..................................................................................................................... ....................................................................................................................................................................................................... U Nature of Repairs or Alterations-Answer when applicable............................................................................................... .....................................................................................................................................I------------- .......... ...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I I= 5 of the State Sanitary Code— The unders gned further agrees not to pl ce the system in operation until a Certificate of Compliance has been i�sued by boVfd of health. to p, ce Si d.. -------------- ---------------------------------- ............. Date 7Z Application Approved By.....-- .................................. .... Ld DWe Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................... ----- ................................--------------- ---------------------------------------J_ I - — Date Permit No......................................................... Issued_......77 Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA 7f, No........ _......... %6 Finc..... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA 4T A.� _._.140_t!P.4.......... .......OF.......... ... .. ......... Appliration for Disposal Works Tonstrurtion Frrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Systeqi at: • ............................................................................................... ....................................................................... Location-Address or Lot No ........ ......... Owner Addres s .................................................................................................. .................................................................................................. Installer Address U Type of Building Size Lot..'_..... Sq. feet �j Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder 114 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria Other fixtures .................................................................................................................................................... Design Flow.............:................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity__-.L*......gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.............._..... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dos* nk Percolation Test Results Performed by"n)f 5;'4 A ;�. Z.......... ......49...4. 1U.64.......... Date... Test Pit No. 1................minutes per inch Depth of Test Pit._.................. Depth to ground water........___.,_._...._.... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ........... ..... --- ----- ................. n�............................A-------— ............................. 0 4 ...... Description of Soil........-_0..........44--ge-.., -w -------------------------------A- ....................../*4.:. ......... ......12. ......................................... .................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .................................................................................... .................................. .......................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT L_ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. SlgAed ------------ .... . ....................... Date Application Approved By_.- zzl�ft_;Z 11. --------------- D-;?e Application Disapproved for the following reasons:................................................................................................................ ....................................................................................................................................................................................................... Date PermitNo.......................................................... IssuedL......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL -.......... / . ................... (9rdifiratr of Tomptiattv THIS IS 7,Z T That the Individual Sewage Disposal 'System constructed or Repaired by........... 7 ---------------- ....... .............. --------------------------- - --------------..... . ..... htsta .... . 7et 44,11:4 .... ..... ..A............................... at.... -------- has been installed in accordance with the provisions of Vr n- E' 5 of The St e Sanitary (k&,as described in the application for Disposal. Works Construction Permit Nca�_:j........................ Zdy- ,;Arl.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,CONSTRUI AS GUARANTEE I T THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............:1-27...Z$............... CIIZL_� --- ---------- ,IAspector........ .........------------------- The t e THE COMMONWEALTH OR�,MASSACHUSETTS BOARD �H HEALTH ..............OF..........Zw"'n,"................................................. iOl A— off ........... FEE;...rd..!Z............ Disposal rkp udion Vvrrmit Permission i)>reby granted....e,. ........... ... .............................................. ............................ t c ct PAndi i ewag�e o cinstr or ,epair ajiyln iwi a /Vispe# Systenj, at Street as shown on the application for Disposal Works onstruction FVnut 76,11 ...ated.D ........................... t ------------------- X-10*.rd tof Nil • - DATE..:................................7.......................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS a E:1 0 I r-u.. 4d -v sepric RI►�Wj _ TA rl K 1 V W'4L t Lswaf1 A Is IT S t_ tZ T t i E..17 I L C. t �aa37� �' "�"t 1.�� 1.bCh T 1 U,►-� `'��::� . . x d A'(;L %4 V,:Q 6 CM- P"ILVS Vl/ ,Q�.iL7 rs1�` '�+�.' �'Ir G��t�I��T�r 4,C�' T'►r1.- - _ 1.1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A 'V / y TITLE 5 OFFICIAL INSPECTION.FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. la Owner's Name: M� Owner's Address: 0 PARCEL . Date of Inspecti Z4 QQQc!Z LOT Name of Inspector: please print). `�' �• ,aof4o�� I399 Company Name. �j, C.' RECEIVE® Mailing Address: ^0 QQ(a.�g Telephone Number: s�jQ&''� 7'J/ • � �� APR 2 3 2002 TOWN OF BARNSTABLE CERTIFICATION STATEMENT HEALTH DEPT. m I certify that I have personally inspected the sewage disposal system at this address and that the orma ion rsp e 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 15.00.0). The system: Passes Conditionally Passes2 . ZaiIsls eds Further Evaluation by the Local Approving Authority. Inspector's Signature: Date: �— The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system.is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the.report to the appropriate regional office of the. DEP:The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and.Comments ****Thii report only describes conditions at the time of inspection and under the conditions of use at that A time.This inspection does not address how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/I.5/2000 page I T t. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CER/TIIFICATION(continued) Property Address: T.°, V Q �yQ�, JL--1t4 .Owner.• Date of Inspection: Ufa U 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: 1-WAq B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the 'replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing`tank is replaced with a.complying septic tank-as approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or'high'static water level i -the distribution box�due.tobroken or obstructedpipe(s)'or due to a'broken;settled or uneven distribution box:System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or.replaced ND explain: The system.required pumping more than 4 times a year due to broken or,obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):_ broken pipe(s)are replaced obstruction.is removed ND explain: 2 Page 3 of 1'1 OFFICIAL.INSPECTION FORM,-NOT FOR;YOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CER�T/IFICATION(continued) Property Address: (AM Lit Owner: i �t/�, '0 Dr y __ ._ .. Date of Inspection:CJ4V44 ` % 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 ma 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 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 aseptic 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.: 3 Page 4 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM`INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 Owner: Date of Inspection: / c')jc)Q 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 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 6"below invert or available volume is less than %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 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 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.] A (Yes/No)The system fails. I have determined that one or more,of the above failure criteria exist as described in 310 CMR 15,30.3,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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat or answered it Section D above the large system has failed.The.owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304..The system owner should contact the appropriate regional office of the Department. 4 ,.Page 5 of I I OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE.WAGEDISPOSAL SYSTEM INSPECTION'FORM -.PART B. CHECKLIST Property Address: f �� Owner: Date of Inspection: / �PPJ!/ 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? V"'_ Has the system received normal flows in the previous two week period? V 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? V_ 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? .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 no Existing information.For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of l 1 OFFICIAL•INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /&/) � - ��, [� le - lo /ll� 0 Owner:. Date of Inspection: 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): : Number of bedrooms(actual): a. DESIGN flow based on 310 CIvIR 15.203 (for example- ]l:0 gpd x#of bedrooms): Number of current residents: Does residence.have.a garbage grinder(yes or n4,4AC— . Is laundry on a separate sewage system (yes or no): if yes separate inspection required] . Laundry system inspected(yes.or no).� Seasonal use: (yes or no): Water meter readings; if available(last 2 years usage(gpd)):DD Sump pump(yes or no Last date of occupancy:&Lj� COMMERCIAL/INDUSTRIAL�_/Y& Type of establishment:. Design flow.(based on 310 CMR.15.203): gpd ' Basis of design flow(seats%persons/sgft,eic.): 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: readings, Last date of occupancy/use:. OTHER(describe): GENERAL INFORMATION Pumping Records Source<of information: Was system pumped as part of the inspection(yes r 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) —Tight tank -Attach a copy'of the DEP,approval —/Other'(describe): iG�1 J4'S Approximate age of all components,date installed ' P � . (�f known and source of informs ) ton: Were sewage odorsAetected when arriving.at the site(yes or no): 6 Page 7 of 11 OFFICIAL.INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL:.SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: tV �C:VfIG(JY Owner: Date of Inspection: d BUILDING SEWER(locate,on site plan).. Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water.supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: tr_I(locate on site plan) /S-„� 0 � Depth below gra� /!� � Material of construction:4Zconcrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �. 'x(0`X � Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Zd Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to b ttom of outlet tee or baffle! How were dimensions determined: Comments(on pumping recomme ations, Inlet and outlet tee or baffle condition;structural integrity, liquid levels s related to outlet invert,evidence of leakage,etc.): (.� ii 1Z GREASE TRAP ocate on.site plan) �� _ » Depth below grade:._ Material of construction:_concrete_metal_fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART C SYSTEMINFORMATION(continued). Property Address: " (�V p Owner t `—, Date of Inspection: Got 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/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: 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.): PUMP CHAMBER(locate onsite plan) Pumps in working order(yes or no): Alarms in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART. C SYSTEM INFORMATION(continued) Property Address: 9 6w A V Owner Date of Inspection: 75 SOIL ABSORPTION SYSTEM(SAS):. ✓(locate on site plan,excavation not required) If SAS.not located explain why:. ype .. eaching pits,number: T leaching chambers,number: 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, ' R CESSPOOL�S:/]&--(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.): PRIVYV (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY.ASSESSMENTS :SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /n PAt4-�;,Vq �`� "A- Owner: o% Date of Inspection: ,.�:)OOa 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. av- 1 /d ► f 0 10 • Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION;(continued) Property Address: ¢J Owner: Date of Inspection: / 0 vZ SITE EXAM, Slope Surface water Check.cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from.system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) /Accessed USGS database=explain: You must describe how you established the high ground water elevation: X/ � 11 " Permit Number: Date: Completed by:. �� HIGH GROUND-WATER LEVEL COMPUTATION Site Location: l37 y / l-I/f Lot No.. Owner: mrt/�i/a /�/'l Add.ress:. �l�i� Contractor: �LI�1�D G� ! �/F�.7• Address: ✓ / / . Notes: i /�l STEP 1 , Measure depth-to water table tonearest.1./10'It..............................................................-............:............ .Date month/day/year STEP 2 Using.Water-Level.Range Zone and In-dex WelI.:M:ap:locate site and determine: 0.AApro.priate.index well.................. ZJ Z OWater-level range zone.............-.....................................:.:_..: V STEP...:3.. Using month ly.repo.r-t,:•"Current Water Resources Conditions" determine current-depth to water level for index well ...:....................... /fz month/year STEP. 4. Using,Table.o.r.W-ater- tl Adjustments for index well (STEP 2A:),.current depth to water"level for index well (STEP 3)., and water-level zone (STEP 2B) L I determine water-level adjustment ...............................................................................:...........-..:. STEP-.. 5 Estimatedepth to.high water by subtracting the` water level adjustment.(STEP 4) from measured.depth to water level at site.(STEP'1) .................................. f(� ................. Figure 13 Reproducible compufiafion form: La _ �f Telo ; MEMO