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HomeMy WebLinkAbout0007 IRVING AVENUE - Health 7 IRVING AVE, HYANNIS A = 0 o 0 AVe c� All r wall Q tI WA# / — 6AZA a Fwon HouSE ` a i y i �* `ggluEp— { .. ...... .......... .......... ......... ...... ... ... .. .. ........ ....._ .. ...... .. r w ........... • i { r t i ? i CsyY1�S"C 0 -a a { 1 1 � ` } A� . �au milt x f,► COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:7 Irving Ave Hyannisport NameofOwnwEldredge Arnold Mass . Address of Owner: 7 Irving Ave 3/12/99 Date of Inspection: Hy annisport ,Mass . 02647 Name of Inspector: (Please Print)Joseph P.Macomber J r . I am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000) Company Name: J. P.Macomber & Son Inc . MarTingAddress: Box 66 CentervilIe ,Mass _ 02632 Telephone Number: S n S_77 3 3 2 2 CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se age disposal systems. The system: r 1� ~ Passes _ Conditionally Passes _ Needs Further Ev nation By the Local Approving Authority Fails Inspector's Signatur_ " Date: , The System Inspe4tV 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 ot�Environmentat Protection. The original should be.sent to" system owner and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Pagel of11 �� Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of k►spection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTBA PASSES: LS I have not found any information which indicates that any of the failure conditions described In 310 CMR 1fi.303 exist. Any failure - criteria not evaluated are indicated_below. _ COMMENTS: T o 1 d buy r r00 th® EesePee' shotild sfiould be replaced in trie near Pipe is starting to oval out and settleing . It is starting B. SYSTEM CONDITiONALLYPASSES: to kick pipe uphill . Pitching in wrong direction . JD 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. Indicate yes,no,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. r- /Li•jfQ Sewage backup or breakout or high static water level observed in the:distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box Is levelled or replaced - The system fequired pumping-more than-four-time s-a year due to broken or obstructed pipe(s). The ryrtam VAtyess-r Inspection if(with approval of the Board of Health): - broken pipe(s)are replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirwed) Property Address:7 Irving Ave Hyannisport ,Mass . Owner: Eldredge Arnold Dav of Inspection: 3/12/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: e Conditions exist which require further evaluation by the Board of Health in order to determine If the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WiTH 310 CMR 15.303(1)(b)THAT THE SYSTEI IS NOT FUNCTIONING IN A MANNER WHICH.]MIILPRQ=THE PUBLIC HEALT1iAND SAFETY AND THE Dd1aBONMEKT. Cesspool or privy is within 60 feet of surface water Cesspool or privy is within 60 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 AND SAFETY AND THE ENVIRONMENT: ti 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 SAS Is within 60 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 60 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that th well Is free from pollution from that facility and the presence of immonla nitrogen and nitrate nitrogen is equal to or less than 6 ppm. Method used to determine distance yw (approximation not valid).- 3) OTHER AI-4 11JI19 revised 9/2/98 Page 3of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTi91CATiON(coertirvued) Property Address: 7 Irving Ave Hyannisport ,Mass . Owner: Eldredge Arnold Date of Inspection:3/1 2/9 9 D. SYSTEM FAILS: .You must Indicate either"Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination la Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No i 1/ Backup of•eeWage irrtoiacilitynor••eTatemcomponentdue-qo an overloaded or—c{egQsdSAS-ormcesspod. =�---•�_ _ . Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. 2 Liquid depth in cesspool Is less than 6" below Invert or available volume is less than 1/2 day flow. Required pumping more the 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 60 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 organio•compounds, ammonia nitrogen•and nitrate nitrogen. - .. E. LARGE SYSTEM FAILS: - 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: The 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 health 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•Iswithi9 200 teetof•a-tp;butaf-Y-4"4urfaoil•d►lnklwq.awtw-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 owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. I revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL,SYSTEM WSPECTION FORM PART 8 CHECKLIST ProponyAddrau: 7 Irving Ave Hyannisport ,Mass . Owrw: Eldredge Arnold Data of Insportl«u 3/12/9 9 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. Nona of the systemcompoaanLs.Maaabaart puatip4d4oPatJaa3ttwo- we"o sadstba'rystam haxbaa xecaia:agw6maj Row 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. _ The ate was Inspected for signs of breakout. _ All system components,`luding 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 Leos, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe sit@ 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 owa&r.(wW.nr'r,1ppAn?s if diffalApt fr6QLzwmaj wafer pjnv1�tj wLth infnrmntioapn tha Prn-.nar mairtinn�rv, ..f SubSurface Disposal Systems. I revised 9/2/98 Page 5of11 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION pr.p.rtyAddr,ss: 7 Irving Ave Hyannisport , Mass . Owner: Eldredge Arnold Dau of kupection: 3/12/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: /l!) g.p.d./bedro m. ''ll Number of bedrooms d si ) Number of bedrooms(actual):�Y Total DESIGN flow Number of current residents: e . Garbage grinder(yes or no):y Laundry(separate system) (yes o ):_, If yes, separaielnspection.required - Laundry system Inspected (yes o Seasonal use (yes or no):-1O Water meter readings,if available (last two year's usage(gpd):_/!�_,� `77 ` �" 1��)C Lf- J Lr1lJ , Sump Pump(yes or no):� � 4., 4elQ- Last date of occupancy: 7�--''/ ��� COMMERCIALANDUSTRIAL: ���LLL i1hG� Type of establishment: AM Design flow: d ( Based on 15.203) Basis of design flow IV Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)-dzA Non-sanitary waste discharged to the Tide system: (yes or nol� Water motor readings,if available: Last date of occupancy: LA OTHER:(Describe) AM Last date of occupancy: GENERAL INFORMATION PUMPING R ORDS a "rce f infor ti n: t��� v,� ��' 14W I wm&-, Syste p mped as part of inspection: (yes or no)A If yes, volume pumped: AM gallons Reason for pumping: TYPE OF SYSTEM Septic tan k/&**4busicw-b"/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 A)b_ Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known)-end source of4Aformation: Sewage odors detected when•arriving at the site: (yes or no)1 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrss:: 7 Irving Ave Hyannisport ,Mass . Owner: Eldredge Arnold Data of Inspection: 3/12/9 9 BUILDING SEWER: (Locate on site plan) r Depth below grade:IV Material of construction, ca `iron V 40 PVC_other(explain) Distance from private water supply well or suction line _ Diameter q_ Comments: (condition of joints, venting,evidence of leakage,-etc.) Joints appear tight No Pyidpnr.p of 1Pakngp SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: Vconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is (petal,list age dg 13.age.confumed by Certificate of Compliance 111A(Yes/No) Dimensions: 9 rlr rr,OryG N9r,2'v1),Alb � y�l Sludge depth:��'W— I— _ Distance from to f sludge to bottom of outlet tee orbaffle/xeeZ Scum thickness: .t(�_ Distance from top of scum to top of outlet tee or baffle:-2r,&Cle✓ Distance from bottom of scum to botysln of outle ee or baffle: How dimensions were determined: Comments: (recommendation for pumping,_condidon.of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structuroHntegrity, evidence of leakage, etc.) 'Pump tank annual 1 y_Tnl Pt- R nntl pt- YppQ arp ; r, n1 arc ThP t-nnk ; c ef-rtitrt-viral l'n rQund , T-@Pjr g}}giJ6 PA evJdeRee—eleakage GREASE TRAP: V, (locate on site plan) Depth below grade:/ Material of cons tructionNconcret.4gmetal4)JFi bet glass/YZAolyethylone/111othor(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: N14 Date of last pumping:. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Grease trap is not present revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop"Addrass: 7 Irving Ave Hyannisport ,Mass . ownw: Eldredge Arnold Date at k'p°CdO : 3/12/9 9 TIGHT OR HOLDING TANK: (.�Ltt=(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade:AM Material of construction-dr concrete�VAmeta4eAFlberglassA 4PPolyethylena/�,4other(explain) r Dimensions: Capacity: d4 gallons Design flow: A,4 gallons/day Alarm present Alarm level: A 1 Alarm in working order:Yes No-J4 Date of previous pumping: Vli Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) 11ght or holding tanks ara ng+ 3=eseez DISTRIBUTION BOx:A,�ve (locate on site plan) Depth of liquid level above outlet Invert: Comments: (note-it level and distribution Is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — - — istribution box iQ nest nrusea>; e—oesspeels are - - - SP;ti r tan - PUMP CHAMBER: A, (locate on site plan) Pumps in working order:(Yes or No) 4"A Alarms In working order(Yes or No)--451 Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) ump c ambPr is not racant revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l SYSTEM INFORMATION (continued) PropertyAd4res3:7 Irving Ave Hyannisport ,Mass . Owrw: Eldredge Arnold Date of kupe`ti«" 3/12/9 9 `,p. �,J ] SOIL ABSORPTION SYSTEM(SAS)::���r 0 1 /jIfX)t (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: 6 leaching chambers, number: leaching galleries,number: leaching trenches, number, length: Q leaching fields, number, dimensions: overflow cesspool,number: Alternative system: AA Name of Technology: ! Ld t Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to fine sand . No signs of hydraulic failure or ponding _ Soil is dry . vegetation Is ner-mal . CESSPOOLS:_ (locate on site plan) r� Number and configuration: p�` Depth-top of liquid to it invert: Depth of solids layer: �� Depth of scum layer. .I� Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Overflow cesspool is dry . Comments: (note condition of soil, signs of hydraulic failure, level of.ponding,condition of.vegetation, etc.) Same as above . PRIVY: (locate on site plan) Materjals of construction: � Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Privy is not present . revised 9/2/98 Page 9ofII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) PropenYAddreu: 7 Irving Ave Hyannisport ,Mass . Owrw: Eldredge Arnold Date of 4UP.c60n: 3/1 2/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include t)es to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) o v 0 �Sh— -!('70N J o a+7a9 — i �[f 7 1 tr - Il b J r revised 9/2/98 Page 10of11 • ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddre": 7 Irving Ave Hyannisport ,Mass . Owner: Eldredge Arnold Data of Inspection: 3/12/9 9 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 Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: _Obtained from Design Plans on record bserved.Site(Abutting props servation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _zchecked pumping records -/1"Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 ' , nrn r+rn:•raT.r•t-ern:tm•nmrs-.n•t rsrrrrn::�e-rervrr:�rrre*+rr*+ns•nttt�atsrrer.Rs+ .. �) TOWN OF Barnstable BOARD OF HEALTH 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I �_ �•••T••t�T••._•.•f-�.11T.�.�TTITTT'R.ISI T'{l�:E'Tf T'I1R.'ram.•.-ir'ttTt�ifRlm-T1RTiVpi RfNRIttTTliTi mnn�rmrnrsv�*rr+rr+r•.—rrr•r•�r -..^ -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS ---7 Irving ' Ave Hyanni sport ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # •�, l� 0��. OWNER' s NAME Eldredge Aernold PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & So-ir 'Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or CSty State-tip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (790 ) 1578 - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : S steui PASSED D , The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection whicl, I have con 'ticted has found that the system fails to Protect the public health and the environment in accordance with Title 6 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature t Date ?� One copy of this cer ,ification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HEALTtI. * If the inspection FAILED, the owner or.."operator shall u within one year of the date of the inspection , unless allowed dortrequiredm otherwise as provided in 3.10 CMR 15 . 305 . partd .doc - Massachusetts Department of Environmental Management14 qq 'y Office of Water Resources ®1 TYPE OR PRINT ONLY Well Completion Report R GPSCOPTiL1t , m W1=L1_LE?CA310N" ptft} $ } Address at Well Location: HAOr M@LL ?41R-D Property Owner: Subdivision Name;. Mailing Address: k' Vt ea�rvs~� Vf Ciry/Town: City/Town: tt €,fit Assessors Map. Assessors Lot#: NOTE:,Assessors'Map and Lot# mandatory f noestreet address'available. Board of Health permit obtained: Yes ❑ Not Required ® Permit Number pate issued° Z.,WORt PERFORME#3 New Well ElAbandon ❑ Domestic. > Irrigation Cable �❑J Auger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer ❑ Direct Push ❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud,.Rota -1,R OtherB"Ce 5.WELL LOG _ oC Unconsolidated ConsolidatedeStEgSKE' CI (us � artamarrOftarSrFe W Permeability e � From (ft) To (ft) High Low `�CIS �" S m Other Rock Type, 0 ►$ ?CQ rt K { j= yC kk vo 411- ;' -- WELL CONStRUCTit31{i# 8 AStN R *� �°� Total Depth Drilled From (ft) To (ft) Casing Type and Material Size O.D. (in) Well Seal Type Date Drilling`Complete Al? I� ' if Zla3� SCREEN r _ = s From (ft) r` To (ft) Slot Size Screen'- pe and Material Screen Diameter t`'/{ C99E� tit ,1,tfitatt9`� �7r'�i� ,` 7'c.c 1t) FILTER f GR,OUT 1 ABANDNMEIdT I�IATERIAL q RA fq,A1DItatStldtL iEL �NFQRtATION .. � va�_ y.. .. .,3 �...A..,m . From(ft) To (ft) Material Description Purpose Developed? Yes ❑ No Fracture h I En ancement? _ Yes.. No m Method � (Al 'T sy3 Disinfected? ® Yes ❑ No e2<WELL.i"(=Sfi�ATAmtPRt3DllTl© WEI, S „ 13A `fE !ItI� EL (ALLAfLLa ,_. Yield =Time,Pumped Drawdown to Time Recovery to Depth Below Date Method (GPM) (lirs&min) (Ft: BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) ,. 3�, 4, .` � :+ . . e 'PERMANENT-PUA#P 1 plEJAt)DESS WE,IIulf4Ttlt II�IP +ty jg'a A9 Pump Description gib'` Horsepower Pump Intake Depth : t (ft)- Nominal Pump Capacity (gpm)_ 3 1&-COMMENTS ��`'��'" 17.,WELL DRILLER'S STATEMENT - This well was drilled and/or a ando u er ervisio , according to applicable rules and regulations, and this re o Is. mp c recta t he best of my knowledge. Driller: ' Supervising Driller Signature: Registration #; Firm:L."ker, Date: Rig Permit#: I I I I�6 I I NOTE:.Well Completion Reports must be filed by the.registered well d ller. ithin 30 days of;well completion. i. BOARD OF HEALTH COPY