HomeMy WebLinkAbout0256 CRAIGVILLE BEACH ROAD - Health 256 Craigville'Beach Rd. (Hyannis)
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TOWN,.01?BARI��S TABLE
LOCATION .256 Gr&-CCyj SEWAGE
VILLAGE e 5 ASSESSOR'S MAP &LOT Of b 07
AME&PHONE"NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
,NO.OF BEDROOMS i
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation!,Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility, (If any wells exist
on site or within 200 feet of leaching facility,),' Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 3-00 feet of leaching facility) Feet
Furnished by
✓� r,
t y
,Y
4
LO �R► T-fON SEW G E PERMIT NO.
VILLAGE
INSTA Ll R'S AM[ i ADDRESS
s
OR OWNER
4-
DATE PERMIT .ISSUED
DATE COMPLIANCE ISSUED � �. � �
- t
X- C
s.
� I�
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L. -it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: Fill in please:
s APPLICANT'S YOUR NAME/S: i ngey IV 6cAe h C j/jYq i n i
,r J BUSINESS YOUR HOME ADDRESS: 25(o r t�l/e �e c% -Pa
ah nktJM"9' OZ6el,
TELEPHONE # Home Telephone Number
NAME OF CORPORATION: MOCAO h
NAME OF NEW BUSINESS TYPE OF BUSINESS Qt Mdll ,
IS THIS A HOME OCCUPATION? YES NO
ADDRESS OF BUSINESS tP54 C PQi e �e.Ccca( �s 0�'�/MAP/PARCEL NUMBER . -?,6 7 7 a (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your IJIISil-leSS in this town.
1. BUILDING.CO IS lb ER'S OF �E
This individ al ha e ipfor e an er it re it nts that pertain to this type of business.
Au riz i nat e** _ MUST COMPLY WITH HOME
c MME RULES AND REGULATIONS. FAILL,
COMP7 .
1
2. BO�4 OF HEALTH
This individual has lbee folm2*d f the permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
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()()MMO1.%rNEALTH CF MASSACHUSETTS
j �:rCUTn�E OFFICE OF vIRAmMEN TAL AFF.A.IRS
11EPAR TMENT OF EMrIRONMEN'T'AL PROTECTION
TITLE S
®I4°FICL!#L,INSI'I C:TION FORM—NOT FOR VOLUNTARY ASSEssm[Emrs
SUP.SURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
owner's Name,, _J
gainer's Address' �
Date of Tnspectiod: �A _ RECEIVED
Name of inspector: boa ;print) Nt'K 2001
` lree�
coma ny dame.: gtJ'L..1� �t? e. 1 X
Mailing Address:
TOWN OF 6i RN .1,gt3LE
_ � HEALTH DEPT,
Telspp=one Nnral9er:
CRRTIFICATION STA►TEMEN"x
i ins clad the sewage �sy„teta at this address and that the u►formatiatt t~tp�:�z4ed,
i rxrt*that l have ped' j y i, ct�on.The inspection was performed based or,a.
below is true,accurate and c.�atiplete t i ofoian and nya the
t insce.A on site sewage disposal systems.I amn It��?k:
training and experience in rise Ist t to Sieben 15:W of Title S(310 CMR 1000). The system:
approved system inspsctd.'p
Passes
Conditionally Passes v Authori
W Needs Further EvaluaIdan by the Local Appt o �
yails
�t Date..
inspector's Sipdtture "�"
"fuse system inspector ft" Idm it a cop)'of this +�
reprrt to the Approving Authority{Boar d of glettt!: or
�rithizs 30 days of CO110etiug W3' if the system is a shared system or has a design flow Of :)f 300
he
DEP) r E ad the system owner shall submit the report to the appropriate regional office.P1 vi
gpd or greater,the inspectc i es sent to the buyer,if applicable,and the ap��, ' [�
gpdEP.The original should It tent to*,e;,ystetn owner and�p
authority•
dotes attd'C "
conditions at the time ofin;tpsetior and under�re conditions er be"me oralit;�a,a��.t
****This repi rt only de:scr•lbe; rSorm in the
ti®e.This insetion dots not addrett,how the system still pe
conditions of use.
P�t�113!2000
Title 5 Tnspac't►onloran
Page 2 of 11
OFFICLAL Irl:TECTTON FOIL—NOT FOR VOLiI,TNT•ARVA.SSESSN, 0241 !;
SUBSURJFwM, SENVAGE DISPOSAL SYSTEM INSPECTION FORM
PAIN A
CER'TIFICA1IMN(continued)
Property Address: 08`� _Sf6.`
Slate of Inspection:
Inspection Summary: ClAeck AAC D or E/ALJX cowpWe all of Sectie h D
A. System Poem:
kl have-not found;u;;r informati m which indicates that any of the failure`criteria described in 31 G CNl R
103 or.in 310 C1v1R 15.:;04 exist.Any failure criteria not evaluated'ire usdicated below.
Comments: v `.
B. System C:onditionall;,F%ssp:
One en more systr;rz components as.deaeriled in the"Cpndi 9M Peas„ on nad.to be t�let.etl a
repaired.The;system,'uP(1r..03mpletion of the replacement or ttispair„aS spprQv y the Board of Health,yril I I ass.
Answer Yes, no or not deler.�.ined(Y,1`f,;[�tD)is the for du fql g stategnents.If"not detarmiae�i"pb.s :e
explain.
The septic tank is zatud and over 20 years old'or se
unsound,exhibits subatan:ial inflit,do,z or tank(whether metal or not)is strucarall!d
existing tank:is'replaced witli a co I s; tok failure is imminent.System will pass inspectil:::`if 4be
�'.g AS Fumed by the Board of Health.
'A metal septic tank will I�i:�; inspection if it is y so and,not leakcing and if a Certificate of Coroplia i,;e
indicating that the tank is less than 2®yg rs of m available.'
ND explain:
ObsWil4oa of sews ac bac or break out ot.
obstructed tigh
pi{�e(s)or due UP a �rok sel1jed or �;water level in the,dlSti'Ibution box due tc Ixn�l ;n t7
approval of Board of Healtk): �°e diction box. SysUm Will pass won if(with.
diso,,, boot is Iatested ;r replaced
ND explain:
The system aired p1;raping MOM than 4 times a
Pus inspectionr"f th appt 5r•al of the Board of Health); Yew d�e to broken or obstructed pipe(®),The s Mew ,dll
.broker::pipe(®)are aoplaced
obsu u,.-don is removed
ND expligiin:
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Page 3 of 11
OFFICIAL INSPECTION.FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACH, SEWAGE,DISPOSAL S YSTEM INSPECTION FORM
FART A r
CERTIFICATION(ccrmtitused)
Property Address:
Owner. �
Date of inspectl .—C. 7'
Further Evaluation is.;l t,juired by the llmtrd of Health:
Conditions exist whi:h:require folb ar evaluation by the Board of Health in order to ermine if the say'! :tn
is failing to protect public he d—th,,safety or the eavirOnment.
Sy'teasi'•win past unit n;Board Health determines us accordance with Cltut 15.303(1)(b)
tier .the
�. system is Dot fuact&:nin;in a msenner wbieb will prote,et public bealt ,safety and the etivirermess
•s
_ coapool or privy is within SCE fW of a sulrftce wimp• d or a salt marsh
Ce.�spool or gri s within-50 feet of a bordering vrt
2. System wriU fail nmH:ss dke' rd'of R6iltti( Public Waster Supplier,if slay)ditermines duet it
system is functioning in si manner that pro"
is a peeblis health,safety and envirosa®eat:
The system hats s septic talc send soil s a n sy gem(SAS)end��SAS is wid�ita 100 fie et of:.
surface water sttppl'+ar tribuUcy to a > Y
The system hac a septic ts�:; AS and the SAS j s within a Zone 1 off a public water ssapp:l}.
tanl� SAS stand the SA:;_a within 50 feet of a private:water supply s,►411.
t'ttc:system ba. a,.�eptia .
.T1te sysste�m ltss a/grmed.
t and SAS and the SA9e ism 'a 100 feet but 50 feet ar more frlraa. .
private water supply em as;:c a water anplyS.iS,perfcniwd at aDEP certified laboratory,for colil`o:rM
This.syst P f llutioafrom thht feci.lits s;ad�bacteria rind voiati;.e� a�uods�� tm ties�U�'o ��S ppm,provided tb&t nu a her-the presence of esm en+ nand nitrate nido�cn is°9failure criteria are trieypy of the eeoplysia tnusx be attached m this foram.
s�
3. Other: ._._. ..__..
3
Pap 4 of 11
OFFICIAL.INIij'ECTI®ri FO) —NOT FGR VOLUNTARY ASSESSMEP T,&
SUBSURFACE SEWAGE DISPG&4L WiFSTEM INSPEC71ON FORM
P RT L
CERTIF ICAT'ION(continued)
4
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reeas. "
Property Adci
P'e
Owner:
Date of 1049 I C9
D. System Failure Criteri.t s:ppiitable to all systems-
You jMg indicate"yes"c r'`w)"to®act of the following for g((,itsspections:
Yes No ,
13arclmap of sev+al a:nto facility or system component due to overloaded or clogged SAS or 6etslaa<i1
�- Discharge or pot ding of effluent to the surfice of true grouasd or surface waters due to an ovorloild c! of
clogged SAS or cesspool
Static liquid levol in the disiaibution box above ourlet invert dine to an,oVer,.loaded or clogged&U o
cftspool .
Liquid depth as c esspool is less than b"below invert 3r,avei1sble volume isJess than 14 day flow
Reiquired pumslein.g more tbrua 4 times in the last your due to clogged or obstructed'pipe(s).24',n aber
of times pumped F
Any portion of'tli.e SAS,cesspool or privy is below high grouted water elevation.
4- Any portion of'c wspool or privy is within 100 feet of-'a surface water_ supply or tributaryy to a su,rfii,u
water supply'
Any portion.of a cesspool or privy is wilt e a Zme I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well,
Any portion off'a cesspool or privy is less titan 100 feet but greeter than 50 feet from a private vtalct .
supply well w-.tf�no acceptable water quality analysis:d'f'his system passes 1f the well water,a:rsL I v is,
performed at a DEP certilled faboratary,ft COW"bacteria and volatile orgaaie,coterpinvi '�s
VIP*that t well is fro:from pollution frormm that fa .
p ciltty and the presence of ammuujla
nitrogen and aitrate nitro e
�e le n b mtt to-or Irma flan S
. M le)pm,provided that no other fsilstre:c 14 i aria,
are triggeret A copy of the adalysb sanest be attain tra Obb form.]
(Yeolo)Ime system. .I how.determined that one or more of the above failure criteria exist wi
described in 3:; #C:vM 15.30.3,du reflore tbo sysma fails.The system owner should contact the:B i id of
Health to derma-ire what will.be necessary to cmmKt the failure.
E. large Sytrtems:
To be coinidtred a large:rnletu the system e a facdlty with a design flow of 10,000 Spd to l5j1m
gpd., F
You must indicate eifher')vs"or'4ao"to refute irbuowing:
(The following criteria app. -u)large sys in addition to the c�¢ia above
Yes no
the s;ymm is within feet oiF a surface dr 1nlcing wa t,W supply
the`s;ystem,is wi r'an 200 fleet of a tributary to a surfw,drinking water supply
ttae System' loco xR:�in a nitrogen sensitive area(Intro im Wellhead Protection Area-IWPA)or a irm qme l
Zone H a pubb;+wetter supply well
If you have erect"yes"to any questir m in Section E the sys ease is considered a significant throat,or a¢avve r xl
"yes"in Sec :a D above the large system tees failed.The owns or operator of scety large system considered as
significant at under See-ioa E or failed under Section D shall upgrade the system in accordance with 3.10 C;,IR
15.304. a sys tem owner:huuld contaci,the appropriate region al office of the Department.
d
POPS ofII
OFFICIAL INSI'ECTION FORM—NOT FC-R VOLUNTARY ASSESSMENTS
SUBSURFA!-�E SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART R .
CHECKLUFT
Property Addraw^ V
Owner:! v
Dste of Inspeetio :
Check if the following have been done.Y na must indicate`Yes" or *no"as to!:e of the following:
Yes No
o Pumping inforinati()n was prmoided by the owner,occigxmt,or Board of Health
_ Were any of the<.,ystem components pumped out in the previous two weeks?
( Has te:systeni rd:ee,ived nory sd fibws in the previous two week period?
A' Have lame volunlet;of w9w been latroduc4d to the system recently or as part of ttda inspection.?
Werra as built pia as of the systsm obtained and exam ned?(if they were not available note as X'A.)
Was the facility o tr,fWelling inspected for signs of se wage bacck up?
Was the site ins;acted for sigr:s of break out?
Were all system :o:anpongnts, xeluding the SAS,located on site?
L
_ Were the septic+:sa,k matsh®le`•j uncovered,opened,sid the interior of the tank knspected,for thr�ox. itic"
o baffles or tees,mister al of coxastrut,tion,diumsions,depth of liquid, depth of sludge and depth of Uui;n'
IY _ Wai4 the facility avvner(and occupants if different fn:,m owner)provided with information on dna pr per
tenanee 01.subsurface !ewage daslsa`al syetetns?
The s:lu and locali®,a of the Sull Abaorptiosa System(SAS)on the site Naas been determined bated
no lyd of health.
Existing infotmut:��n.For,exacmplo,a plan at the>ga � .
o1C Deetwmined in ilea:field(if wV of the fiailsare criteria related to Part C is at issue approximation of atarl':e
is unac_ceptable)(310 CM1 I5.3020)(b)]
Page 6 of)I
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OFFICL&L E6PEC'nON FORM-NOT 1 OR VOLUNTARY ASSESSMIr0r.[T
SUBSURFACE SE14'AGE:DISPOSAIL SYSTEM INSPEC'PION FORAM
PARE'C
SYSTEM INFORMATION .
Property Address: Z
14.
owner: _ .
Date of
FLOW CONDITIOIi S
RESMENTIAL
Number of bedrooms(loos 4dt�):� Number of bedrooms (wtual):
DESIGN flow based on 31 D CNEA 15.203(for example: 110 Mid x#of bedrooms):
Number of current residents: CJ
Does residence have a gmbage gcindm•(yes or,no):
Is laundry on a separate i ewuge system NO or no :
(if I a separate inspection required]
uradry ymem d( r no
La s r
Seasonal use:(yes no): I--
Water
Water mew readings,if&I, �g'lable(lest 2 years usage(gpd)):
Swap Pump(Yes or no): A�� .
Last date of occupancy:- 7- _
COMMERC-L4VINDUS'1 IUAL
Type of estabbahment:_
Design flow(based on 310 7C.MR 1S.203):
Beams of design flow(no a'lxxsom/sgf
Gran trap Present(yes ct IuK).
Industrial waste holding teul c system
t Gres or no):
Non-sanitwy waste discharg, o the Title S syste (yes or na):
Water meter madings,if ey4 )able:
Last date of cc e
G'EMRAL JXMA a,nON
Puamplttg Records
Source of information:I
Was system;mmped as pal a:f the inspection(yea or no):
If Yes, volumeg prt�ping:pumped:
Rawson for ___gallons—How was quantity pczoped determined?
R -_-�--
TYP
L OF SYSTEM
Septic tan[4 distribution 1aox,soil absea'psiosi ayst®a
._-_Single cesspwl
Overflow cesspool
_-Privy
-___Shand"am(yes or IM)(if yes,aniCh previous hspecdrni
obtained from system owner;) records, if any)
_lnnovative;'Att�ernative tec:t WIOgy,A�tmeh a copy of the current operation and maintenance contract(tn be
Tight tank _Attmd,e:copy of the DEP a Vmval
Other(describe):
Approximate age of ail coml w;=ts-due rastalied(if known)an,l sow"of information:
--------------
Were sewage odors
B detected w un atrdvineg at the site(yes or no).
f
Page 7 of 11
OFFICIAL INSPLCTION FORM—NOT FOR VOLUNTARY ASSESSA[ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address• SL�.a._'.�✓o((+t 1C+�t
Owner:
Date of Inspect
BUILDING SEWER(locat M site plan)
ed
Depth below grade:
Materiils of construction:__.ant iron —,t40 PVC—other(ccplain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: L (ioca a on site plan)
Depth below grade: 1
Material of cm trttea ,**c=crew_metal®fiberglass_-.Polyethylene .
othter(explWA) _ —__e
If tank is metal list age:_ ::s age confi=ed by a Certificate c f Compliance(yes or no): (attache a cop",
eeatificate) Vo Dimensions: �.
Sludge depth: Q.__�_
Distance from top of slu gs to bottom of oattlet bee or bade
Scum thickness:
Distance from top of scum ,o rep of outlet to or baffle: , off
Distance f m bottom of Seim-.to bottom tee or a't e: -Lz—
Hiow were dimensions deWMwd: structural irate
ty liquicl l.1 gels
Comments(on pumping re,:oj'=endatio,ns, inlet and outlet tee I.ar baffle condition,
as related to ou inver�t,�evil, ee of laikage,
GREASE TRAP:,_,_,(leant"a on site Dlaas)
Depth below grade: tnetai fjberglass.,mil yiene other,
Material of construction _._'on —•
(explain):
Dimensions:
Scum thickness:
Distance ►top of ui top of outlet tee or baffle: �•
Distance from bottom ea:usn to bottorta of owlet we or�aaflfle� —
Date of last p+�mpin •�.._.�
Cotascarms(one p mg rgoommend�``°s,inlet sad outlet tea or baffle condition,structural integrity,llCluie;' :vets
as related to out invert,midence of leakage,etc-): ----•
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Page 8 of]I
O"ICLAL DIS PECTIGIN' FORM—NOT-FOR OR VOLUNTARY ASSESSM asl1!i
SUBSURIFiXE SEWAGE DISPOSAL,SYSTEM INSPECTION FORK[
PiRT C.
SYSTEM EWOML11ON(continued)
Property Address: s ��.
Owner: a4
Date of inipeeban: 4
TYGYii?or)liOY.EfING'ff NYt: (tan;must be porn at tune of inspection)(locate on site plan)
Depth below grade: A.
Material of construction:_ concrete: 6berglais�,pQlyethylene other(explaia):
Dimensions:— �_—__ _
Capacity: r!s
Design Flow:_ aadday
Alarm presemt(yea or no;✓— -- r
Alwm level: :W m in workiusg order(yes or no):�_ d
Date of in _—
Comments(con ' on of,�rnr and Moat switches,at.):
DdS'TRYBTII'IOi°I BC1X: (if present must be opened)(lo;ate on site plan)
Depth of liquid level aboire outlet invert: gr%1
Comments(note if box is keel and distribution to outlets equal,any evidence of solids carryover,any evic4eri,;.e oi'
leakage into out of box,vrc.):
oW, eve -_ ._:�:.� �
PUMP CHA..WBER: _(it)cate on sits:
Pumps in working order(;n=:�ay[<no —
CommentsAlwms in wonting order(y,(note conditi 45f pump chamber,condition of punt and appurtenances,etc.):
R
Past 9 of 11
OF'F'I�': Ai, S PI"�C'TION,JFORt1"d—NOT FOR VOLUNTARY ASSESSMENTS
SITRSURF'A..CE SEWA GE MSPOSAL iNSTIEM INSPECTION F'O ILM
PART C
SYS111EM INFORW11ON(continued)
Property Address:
Owner:
Date of laspectiaa:
SOIL ABSORPTION S'Y:'T:EM(SAS); (baits on site 1 Sian,excavation not required)
If SAS not located explain I-shy:
Typr
inching pit&,number
inching cbmbers,mtitnimr:
leaching galleries,nm:ub,9r
leaching trernches,nutabar,length:.,
leaching fields,numbs r.dimension:i:
overflow cesspool,nu:i.w.
innovative/alternative system Typriname of technology:.
Comments(notx condition ,if.►oil,signs c,f hydraulic failure,level of ponding, damp soil,condition of vejxtsti n,
ftl*
�-
CESSPOOLS: . (cessi:mo,,l moist be pumped as Part of p:ction)(locate on site plan)
Number and c0n8gurAion:
Depth-top of liquid to Wit t invert:�• - —
Depth of solids layer:
Depth of scum layer:
1Dirmenaions of cesspool: .a—
Materials of cems4xuction:
Indication of groundwater W ow(yes o:r no): g;condition of vegetation,
II9 01:soil,signs of hydrauuc failure,le det of pondin
COS(mute
PRIVY: (lot atd on 1>"tl;plan}
materials of c:onmctior►:,e. -
Dimensions'
Depth of Solids: --- hydraulic failure,level of ponding,condition of vagetation,ltc.l:
comments(n onditio:.crf soil,sigao of hydra
9 �.,-_ ---- -- — - -- --
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Page l o of 11
OFFI,CL L I1 ,411FECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURF,l+:aE,SEWAGE DISPOSAL'SYSTEM INSPECTION FORM �
PART C
SYSTEM INF0RMA7n'0N(continued)
Property Addlress'
Owner:
Date of GO-Fe'
SKETCH OF SEWAGE 0.SPOSAL SYSTEM ,•'
Provide a".,b of the sawa;le disposal system including ties 0 at least two permanent reference landnu*ks o:
benchmarks. Locate all well! within 100 fret. Locate where publ?c water supply ehters the building.
s
y5
571. 1 r'°
e
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Page 11 of It
OFFIC:UL INStECTION FORM—NOT FOR VOLUN7ARY ASSESSMMN3•'CSI
SUBSURFA4;.'1;:SEWA'IaE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addnes: (24L. ` �Y,q
�
Oaases:
Date of Inslpeettim:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to$sound w,ttu:r f8l"t
please indicate(check)all mi-diods used tu,determine the high 1ptxmd water elevation:
Obtained from system ;lc sign.plans on record-If checked,date of design plan reviewed:
Observed wite(abuttinl;Properry/Observation hole within I:'®feet of SAS)
Checked with local BOtlyd of Health-Wiain:
Checked vdth local¢xaatrators,installers-(attach documentation)
Accessed USGS dataW sc-explain:_.
you muuet describe how yoc txbli ed the hi osad ater elev it
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