HomeMy WebLinkAbout0028 PEACOCK DRIVE - Health 28 PEACOCK DRIVE, HYANNIS
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COMMONWEALTH OF MASSACHUSETTS,
EXECUTIVE QFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL_PROTECTION
TITLE. 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 28 Peacock Lane,
Hyannis,'MA-02601 .a,
Owner's'Name: - John Derby Lawrence
Owner's Address: t
Date of Inspection: August 20, 2008Ica „
Name of Inspector: (Please Print) James M Ford ® ,
Company-Name: JamesM. Ford
Mailing Address:. P.O.Box 49 C)o r
Osterville.MA 02655-0049
Telephone Number: FS08)862-9400
CERTIFICATION STATEMENT. x
I certify.that I have personally inspected:the sewage-disposal system at this address and that the information reported
below.is true,accurate and complete as of the.time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
,j Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ils
Inspector's Signature: Date: -September 1. 2008
The system inspector sha11 subm 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
***.*This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspectioni does not address how.the system will perform in the future under the same or different
conditions of.use.
Title.5 Inspection Form 6/15/2000. . page 1 1 / �
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Page 2 of 1 I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART A
CERTIFICATION (continued)
Property Address: 28 Peacock Lane
Hyannis, MA
Owner: John Derbv Lawrence
Date of Inspection: August 20, 2008 -
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that,any of the failure criteria described in-310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated:below.
Comments:
B. System Conditionally Passes:
One or.more system components as described in the"Conditional Pass"section need fo.be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by Board of Health,will pass.
Answer yes,no or.not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. ,System will.pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health. ,
*A.metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less.than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed.
distribution box is leveled or replaced ,
ND explain:
The system required pumping more thanA 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
s
obstruction is removed
ND explain:
Page 3 of 1.1
OFFICIAL INSPECTION FORM.-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued),
Property Address: 28 Peacock Lane
Hyannis,MA
Owner:- John Derby Lawrence
Date of Inspection: August 20, 2008
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to detennine if the system
is failing to protect.public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in'a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in.a manner that protects the public health,safety and environment:
The system has a septic.tank and soil absorption system(SAS)and the SAS.is.within 100 feet of a
surface water supply or tributary to a surface water supply.
The.system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. .
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for colifonn
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 1'1
OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
Property Address': ` 28 Peacock Lane
Hyannis. MA _ Y
Owner: John Derby Lawrence
Date of Inspection: -August 20, 2008
D:. System Failure Criteria applicable to all systems:
You,must indicate either;`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 .
Liquid depth in cesspoolis less than 6"below invert or available volume is less than 'h 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. r .
✓ 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 i of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supplywell.
✓ Any'portion of a cesspool or privy is less than 100 feet but greater than 50 fe.et.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.]
No (Yes/No)The system fails; I have determined that one or:more of the above failure criteria exist as
described in 310 CMR 15.303,.therefore the.system fails. The,system owner should contact the Board of ,
Health to determine what will be'necessary to correct the failure:.
E. Large System:
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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.>The.owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should:contact the appropriate regional.office of the Department.
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART S
CHECKLIST
Property Address: 28 Peacock Lane
Hyannis, MA
Owner:. John Derby Lawrence -
Date of Inspection: August 20, 2008
Check if the following have been done:. You must indicate"yes"or"no"as to each of the following:
Yes No
✓ . Pumping information was provided by the owner,occupant,or Board'.of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received'normal+`flows in the previous two week period?
p -
' 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 backup?.
✓ Was the site inspected.for signs of break out
✓ Were all system components;excluding the SAS,located on site
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
r. of the baffles or tees,material of construction,dimensions,depth of liquid,de th-of sludge and depth of scum?.
P 9 p g p
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)].
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Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION
Property Address: 28 Peacock Lane
Hyannis, MA
Owner: John Derby Lawrence
Date of Inspection:. Au_aust 20, 2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on,310 CMR 15.203 (for example:.110 gpd x#of bedrooms): n/a
Number of current residents: 0
Does residence have a garbage grinder(yes or'no): No
Is laundry on a separate sewage'system(yes or no): n/a [if yes separate inspection required] '
Laundry system inspected-(yes or no): .No
Seasonal use(yes or no): No
Water meter readings, if available(last.2 years usage(gpd)): Unavailable:
Sump Pump(yes or no): No
,Last date of occupancy: Weekend use
COMMERCIAL/INDUSTRIAL ,
Type of.establishment:
Design flow(based on 310 CMR 15,203):' gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)'
Non-sanitary waste discharged to the Title 5 system(yes or no): '
Water meter.readings; if available: .
Last date ofoccupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records.
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): 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):
Approximate age of all components,date installed(if known)and source of information:
Date of installation 8130185
Were sewage odors detected when arriving at the site(yes or no): No.
6. .
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION(continued)
Property Address: 28 Peacock Lane
Hv"annis. MA
Owner: John Derby Lawrence
Date of Inspection: August 20, 2008
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials o£construction: _cast iron 40 PVC other,(explain):
Distance from private water supply well.or'suction liner
Comments(on condition of joints,venting,evidence'of leakage,etc.):
SEPTIC TANK: ✓ (locate on site.plan)
Depth below grade: 12„
Material of construction: ✓ concrete _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:. 1000 Qal.
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 5„
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: > Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.).
Cement baffles were•present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
GREASE TRAP: None (locate 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.):
Page 8 of 11
OFFICIAL INSPECTION FORM NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) r .
Property Address: 28 Peacock Lane
"Hyannis. MA .
Owner: _ John Derby Lawrence
Date of.Inspection: August20,2008
TIGHT or HOLDING TANK:. None (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 alanm and float switches,etc:):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 'Even
" 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.):
No solids were present
PUMP CHAMBER: .None (locate on site plan)
Pumps in working order(Yes or no):
Alarms in working order(yes or no)'
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
..O
} 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: 28 Peacock Lane
Hyannis,AM
Owner: John Derby Lawrence
Date of Inspection: August 20,2008
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -4'x 6'(600 gaL)
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,etc.):
The pit was dry. There did not appear to be any signs of failure. The bottom to tirade was 7'.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater-inflow(yes or no):
Comments-(note:condition of soil, signs of hydraulic failure,level of ponding,,condition of vegetation,etc.):
PRIVY: None (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'-NOTFOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION.FORM' :
-PART C
SYSTEM'INFORMATION co( nd ued)
Property-Address: 28 Peacock Lane
Hyannis. MA
:Owner:
John Derby'LawrMce .. .;
Date of Inspection: August 20. 2008'. -'
SKETCH OF SEWAGE DISPOSAL SYSTEM.—,
Provide a sketch of the.sewage,disposal systern including ties to at least two permanent reference landmarks or..
benchmarks: Locafeall wells within 100 feet. Locate where public water supply enters the building.
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10
i Page 11 of 11
OFFICIAL INSPECTION FORM"-NOT-F.OR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM
PART C
- SYSTEM INFORMATION(continued)
Property Address; 28 Peacock Lane "
Hyannis. MA
Owner: , John Derby Lawrence
Date of Inspection: August 20, 2008
k
SITE EXAM
Slope
.Surface water.
Check cellar
Shallow wells
Estimated depth to ground water 20+/-A 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: Topographic and water contours maps
Checked with local excavators,,installers-(attach documentation)
Accessed USGS database-explain:,
You.must describe how you established the high ground water elevation:' ,
Using'Barnstable topographic and water contours maps the maps were showing gpproxiinately 20'+/-to ground water at this
site. 4 -
This report has been prepared only for.the septic system and components described herein. This septic_system has been.-
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the'system will
function properly in the future. There have been no.warranties.orguarantees; either expressed,,written or.implied
relating to the septic system, the inspection,this report andlor:any components of the septic system which have not
been located and inspected.
_ 11 '
4
�11 � 30
I COMMONWEALTH OF MA SSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
APR 0 8 2003
TOWN OF BH.�NSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 28 Peacock Drive
MAP 2(,09
Hyannis, MA 02601 PARCEL, ; 20"�
Owner's Name: Paul DeCenio LOT -)A
Owner's Address: Same
Date of Inspection: March 25, 2003
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford Map:269
Mailing Address: 'P.O. Box 49 Parcel:207
Osterville,MA 02655-0049 Lot: 7A
Telephone Number: (508)862-9400
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Need urther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: March 27, 2003
The system inspector shall sub 't 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
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART,A
CERTIFICATION (continued)
Property Address: 28 Peacock Drive
Hyannis, AM
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes.
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
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 in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the.Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Peacock Drive
Hyannis, M4
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the.environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 aseptic tank and soil absorption system.(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Peacock Drive
Hyannis, MA
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ Liquid depth in cesspool is less than.6"below invert or available volume is less than '/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 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.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large.system the system must serve a facility with a'design flow of 10,006 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
"yes"in Section D above the large system has failed. The.owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 28 Peacock Drive
Hyannis, MA
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
Check if the following have been done: You must indicate`yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period ?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection.?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components, excluding the SAS,located on site?
✓ Were the septic tank manholes 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
I
Page 6 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 28 Peacock Drive
__Hyannis, MA
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: None on fle-per treatment plant
Was system pumped as part of the inspection(yes or no): 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):
Approximate age of all components,date installed(if known)and source of information:
Aug. 30185-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6 \
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Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive
Hyannis, MA
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
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: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _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: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid,levels
as related to outlet invert,evidence of leakage,etc.):
Baffles were present. The liquid level was even with the outlet invert. There were no signs offailure Recommend pumping every
3 years.
GREASE TRAP: None (locate 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
t
f
Page 8 of .l 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 28 Peacock Drive
Hyannis, MA
Owner: Paul DeCenzo
Date of Inspection: March 25,2003
TIGHT or HOLDING TANK: None (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: Qallons
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: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive
Hyannis, MA
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -4'x 6'(600ga1.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number,dimensions:
overflow cesspool,number:
Innovativelalternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.):
The pit had 1'ofwater on the bottom. The scum line was at the same level. There were no signs offailure The bottom to grade
was 7'.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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: 28 Peacock Drive
Hyannis, AM
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
4 Map:269
Parcel: 207
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 7A
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.
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' Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive
Hvannis, MA
Owner: Paul DeCenzo
Date of Inspection: March 25, 2003
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 exc
avators,
ors, installers- attach docume
ntation)
Accessed USGS database-explain: ( )
You must describe how you established the high ground water elevation:
The bottom of the leach pit to lzrade was 7' On the last inspection I hand auizered down on the bottom of the leach pit to I P
below.erade, and no water was observed
This report has been prepared and the system inspected and passed as of the date of inspection. This report is .
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
COMMONWEALTH OF MASSACHUSETTS t° 6
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .�
DEPARTMENT OF ENVIRONMENTAL PROTE ION �SE• ,z
ONE WINTER STREET, BOSTON MA 02108 (617)292 o Clqrg
{ �r JUAI
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s . ��� ,.
„ Secretary
ARGEO PAUL CELLUCCI -DAVID B.STRUHS
Governor 1 Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 28 Peacock Drive, Hyannis, AM Name of Owner: Richard Eid
Address of Owner: 35 Saratoga Drive
Date of Inspection: June 13, 2000 + Worcester, MA
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 269
Telephone Number: (508)862-9400 Parcel: 207
Lot. 7A
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 sewage disposal systems. The system:
✓ Passes
Conditionally Passes
Needs Further Evaluatio y the Local Approving Authority
ails
Inspector's Signature: Date: June 15, 2000
The System Inspector shall submit�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
revised 9/2/98 Page 1of11
Printed op �
Recycled r
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: i 28 Peacock Drive, Hyannis, MA
Owner: Richard Eid
Date`4f Inspection: June 13, 2000
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
✓ I have 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:
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.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
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 required pumping more than four 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
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Peacock Drive, llyannis, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000
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 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 SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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 AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to 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 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 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) OTHER
revised 9/2/98 Page 3of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Peacock Drive, Hyannis,MA
Owner: Richard Eld
Date of Inspection: June 13, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or "No" as to each of he 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 is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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.
Liquid depth in cesspool is less&an 6" below invert or available volume is less than '/z 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 priNy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or priory 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. 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 indicate either"Yes"or"No"as 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 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 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.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 28 Peacock Drive, Hyannis, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000
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. (*The house was unoccupied.)
✓ _ 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 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 conditions 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)
[15.302(3)(b)].
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 28 Peacock Drive, Hyannis, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 0
Garbage grinder(yes or no): n/a
Laundry(separate system)(yes or no):No; If yes,separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last two year's asage(gpd): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: rand(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
None on file-per treatment plant.
System pumped as part of inspection(yes or no): No '
If yes,volume pumped: gallons
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,Etach 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(if known)and source of information: Aug. 30185-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
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_ r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive, Hyannis, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000.
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 12" .
Material of construction: ✓concrete metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age Is age'confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle. 30
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: Measuring stick
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.) The baffles were present. The liauid level was even with the outlet invert. There were no signs of leakage. Scum
and sludge were minimal.
GREASE TRAP: None
(locate 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:
(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.)
'I
revised 9/2/98 Pagel of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive, Itiawds, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: —
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The D-box was located, but
not due up. There were no signs of failure in the leach pit.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive, Hyannis, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓
(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: 1-4'x 6'
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,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
The pit was dry. The scum line was I'up from the bottom. The bottom to grade was 7'. There were no signs of failure.
CESSPOOLS: None
(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(cesspool must be pumped as part of inspection). '
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY: None
(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.)
revised 9/2/98 Page 9ofll -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive, Hyannis, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000
Map. 269
Parcel: 207
Lot: 7A
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)
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revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Peacock Drive,Hyannis, MA
Owner: Richard Eid
Date of Inspection: June 13, 2000
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
_✓ 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
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. &ust be completed)
The bottom of the pit to grade was 7'. Hand augered down 4'in the middle of the pit to 11'below grade, and no water was
observed. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site (MI W 29, Zone C,
5100), was 2.S'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function property in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11 of11
r .TOWN OF B STABLE
LOCATION ag PEA GO Gh r. SEWAGE #
VILLAGE 14 Annis ASSESSOR'S MAP & LOTarV9 .10"7
INSTALLER'S NAME&PHONE NO. 07- 7 A
SEPTIC TANK CAPACITY /OM 641,
LEACHING FACII.TTY: (type) 9 X to ' P"r (size) G OD (,A)
NO.OF BEDROOMS
BUILDER OR OWNER V Iece,I2n
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 acility) Feet
Furnished by �1SACG7t0n S F01-C4
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d TOWN OF BARNSTABLE
LOCATION 4A PeAe-Oc k r%n t, SEWAGE # FS" SO LO
VILLAGE 14468M15 ASSESSOR'S MAP & LOTd(P9 o;b1
INSTALLER'S NAME&PHONE NO._1 lei SC o 1 I 1 "7 A
SEPTIC TANK CAPACITY /M
LEACHING FACILITY: (type) P,�' (size)
NO.OF BEDROOMS Rt G� � £'
BUILDER OR OWNER
PERMIT DATE: L'I2' rs S' COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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• � O � g � t Q,
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THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
IL................OF........ . }:AJQ.V..fwk�. ...................................
, pptiratiou for UWpatia1 Mirkii Tous rurtiurt Permit
Application is hereby made for a Permit to Construct (>e-) or Repair ( ) an Individual Sewage Disposal
System at:
-k..._`.�2 •----•L�.! . ----------•-. •---•------•••..............�1.-_.........................................................
.........
Lo tin ddress or Lot No.
Own Address
a -•-•._....••-� .-� 1.. .G .. . ..................••-•-•-••-••----... ........................® =
Installer Address T—
UType of Building Size Lot....lfap_�_7S....Sq. feet
�-, Dwelling—No. of Bedrooms......._____................................Expansion Attic (tea) Garbage Grinder (Sp)
'4 Other—T e of Building a Other—Type g .1NMQ__�!v..... No. of persons......Y................... Showers (Z•) Cafeteria �iJ)
Other fixtures --------_P_D_ -S: ------•-------------- . •.
W Design Flow...........3?j-0.....................gallons per person per day. Total daily flow........ ..........................gallons.
WSeptic Tank—Liquid capacity. OW_gallons Length-----lD----- Width-------&...... Diameter----L........ Depth...&..........
x Disposal Trench—No...N�l� ._. Width.................... Total Length.................... Total,leaching area....331------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area ._..............sq. ft.
Z Other Distribution box ($4 Dosing tan (
- f/
Percolation Test Results Performed by �PJ_�.__. �mtcew� `___.._.._... Date... __
p p �epth to ground water----16��..............
Test Pit No. 1._ _. minutes per inch De th o Test Plt___._(_�—......
fX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .......................•••-•-•--••-••-•.--••••••-•-•-•••...•-••-•--•••••••..............•-------•-=---....--•-----••-•---••-••._........-•-••-.....----•••..
® Description of Soil----•----•--...O.-_1.....LAsi`=v.'K--- --Sup-650i.L.........................................................................................
U .............•----••---•••••• ........ ••--- 8 e a 5 ----•-----------------------•---................................................
••-------------------------•-.............V• -------1 A Futar...... 'G b'....;4)a$...-----•--------•---•---•---•---•-•------••---------•---•---•---•-------------•-.
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 TI'1"I.1 5 of State Sanitary Code— The undersigned further agrees not to place the system in
operaticcr-4intft Certificat ompliance has been issued bye board of,health.
7r �algs-
Sigd ----------- •-•-•--••--•......----•-••---••-••••... . ....
APPlication Approved By.... •••• ..... ...: ................. -------- ----•-•-- --•._....e . .
Date
Application Disapproved for the following reasons----------------•-----••-------------•--------------•---•.....................................................
..............................................•....•••-••••.._...--•--••.....••••---••---••-•••••••--••---••------••--•-•-------•••------•-•---•••-•••••......-•-------•••......---•••-•-•••......••---
Date
Permit No......... - ........ Issued.............••-•--••--••-•---•_..-------- ..._..
Date
1 I#jft(5E ftZrZst rn-;PT to u uP-c Lx r-- (AUS; - € urvtD QA&)0 P16�&
l
A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t�c vl.................OF......
ApplirFation for Disposal Works Tonotrurtion thrmit
Application is hereby made for a Permit to Construct (Y-) or Repair ( ) an Individual 'Sewage Disposal
System at:
Location-Address , U _ or Lot No. ....................................
-- -
......................«.--•......._._...._..:.._........•......-:...._..............._.._........ .......... ..
Addre
✓ _ Owners Address-r
Installer Address
Type of Building Size Lot....!...........1 .....Sq. feet
a Dwelling—No. of Bedrooms._.... - ................................Expansion Attic (J6) Garbage Grinder (gi(3)
aOther—Type of Building ............................ No. of persons.....{f.................... Showers Cafeteria (.1o)
rfixtures .._...... '-- .............................................................
Design Flow.-_Other fix' gallons per person per day. Total daily flow------- :?~............................gallons.
WW 1 t c�JLength ,,' U•----- t�
Septic Tank Liquid capacity-' ______ _________ Width____.... Diameter._..._.--------- Depth.. --.-------
x Disposal Trench—No.. Nt:'.... Width.................... Total Length.................... Total leaching area..__: r!.....__sq. ft.
Seepage Pit No..................... Diameter.................--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) p �l
Percolation Test Results Performed by...72_.f- ,./!a___...!�%.•? fL:f.4_�: _t__._._.._.__ Date...,:!5: =�
►a cd ,� -_....
Test Pit No: L Z.__..__.minutes per inch Depth of Test Pit_...).. _....._. Depth to ground water...!.:: ...............
fuel ,n Test Pit No. 2................minutes per inch . Depth of Test Pit................... Depth to ground water.......--...............
A '7,, 1. R1 ei-, � `_.o r.1.<, �1
Description of Soil
................ .........................................................
V ---------------- -----------------••..-- .---•-•-fit_-.-_ _...,......._h. .t e ----•• � ----••---------•----•---•-----
� ' ....... t �
(zl It ` 1 t)' ' t- I A%x I I it h a d O_'b.......... ... -
k 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 TITLE 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.
.............•.....
Date
Application Approved By '` 4 ��; _._ .., ram;. �r-;:''2,;> I .
--•--
ate
Application Disapproved for the following reasons:..............................................................--------------•--................................
• ••••-•-•-••--------•--•-••-------......_.....--•-----••-------------------------••---------••---------•-•......----
Date
Permit N,o. �` Issued---------------•---
6`n It7-t> -c� -� u 2 rate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��7(ca....................0F..... .r' "t d'�7lri f
.............. ..............................................................
Trrtifiratr of TontpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,e or Repaired ( )
,{{ Installer''•
has been installed in accordance with the provisions of TIT"LE'' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.______ _ dated.__.._. =� �.ly_ ._._.._....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UE® AS A GBJRj TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
g- � � �5
DATE....................•---. ....................... Inspector........------ . .... ..----- - .._. --•--....................
THE COMMONWEALTH OF MASSACHU TTS 9AIA "
BOARD OF HEALTH
...............................LtiJ't� ...........O F.........l a............. s S.. .i ...... 1,_ .........
Disposal Works %onotrur#ion untit
Permission is hereby granted........:.:..:. 1 - ..............................."( {
r ..........�......--- ---------•---••---•--••---•••--•--••-••......-•.............._•_....
to Construct (j-) or=,Repair ( ) an -Individual Sewage Disposal System �
at No....l. 1.......2:!!...._.._ '"..a r r ( T.,r t., -' =1 = __S_ E/..-'.::7 �1
Street '
as shown on the application for Disposal Works Construction Permit No. c.�Dated..__,_ ___ ----......
�«>
-- � ;.............
Bo r
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
t '
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!4 Tc"GLl SECT':L 7.'E , K
> ;> Eat 1T c� r .1 RlE3,[RT �e
No 3Ei7 1095tT.
O Q
LEGEND
EXISTING SPOT ELEVATION , 0x0 ..r.: �.
EX!lTIN® CONTOUR ---- 0 - - CERTIFIED PLOT PLAN
a'FINISHED SPOT ELEVATION, 40 - 7,A p,:AC—OC-k D lv'E
rFINit'LE® .CONTOUR 0: W. 1-l/A 1c/iyisPoa
y
NQTEt 'The aocation of any existing undergi-ound sewerage;
wel'1"s,- or other' utiliti;es .shown on this plan is .approx- IN
imate,-only as d„terminedfrom records and/or verbal \
information. The,.contractor is responsible for the �A ,1 rA.9LJASS.
.verification: of the existing locations in the field. SCALES / "=40' DATE 4 /12--'9A_r
f DREDGE ENG/NEER/NG Cal IN <
`JE�, CLIENT.______,_._ i CERTIFY -THAT THE PROPOSED �
EGISTERE REGISTERED JOB NO.&10 c� BUILDING, SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS t
DR BY 1
ENGINEER RV OF BARNSTABLE , MASS.
7.12 MAIN STREET ' CH. BYE
a HYANN I S, :MASS.
SHEET-L OF 0 E REG. LAND SURVEYOR
7-
{ti:
t`
t .� x r .v',f ,y _ •ir � ,�,�T ..s$iS,y�ex T a t i s-
• r2 CPT/C .)-ANK OR
F fTM s w
N... GEr�C/,iING PIT �iRE IyORL= 7-Nf1N :/2"BE40tV
•,' �.Jo.F'J'. MIN ��-� � �<..�- . z JRs4 DE �.�4'O/AM FTER GoNG.�.�r.E FOYER ,;
SHALL e.E BNOIJGNT TO 4f;ADN trXTR/q
Q'PYC P1PE "
CONCRETE h►E.4vy ST /RO/Y Coi/ER Si/ALL'DE [iS�d
M/N: P/TCN. /F/lK ORI✓EWA Y
,: fr l CONCRL�T�
I 1 : Z M/N.
.A �, ff .40E COVER CLEAN 5'ANO
B,4CXF/L4
4_
4 : $CHED tJUG 4O "' : s _ 2'LAYER.
,t ,. T ,p • O ivy O e �F //8 1_-V 6
P/pz CPA dr /+f 1 N.PlTCN WA 5 NFD 57NE
SEP7'/C .,,TANK �<: •, •;�
� • �, i; . BOX � +_�_, •:• 8.• • � • •�� � � �' 3/ �2
=_ •a'• DEPTt/ •.. • �.a �YASHED STdNE
" • 0 1 f 0 • • • • 1 ! ! e
...• D _ //3 :. .,` '.. . ., • m.. f • • • .• • • • • ► .•, P/C"ECAS T SEF-P4 GE
v
7 eM —,Ay a -e• • • s .e • •.f • o o O/7 OR �V/✓
111/Y-AT e'L EVAT/GNs i r r c�PfIG/7 Y
INYERT AT EUILD/NG 3 3 v FT` :. . � ,3! 6 t•T D1,4M•
INLET SEPTIC TANK . 3 i 2 f T. . /z FT APIA 1. �CSi�E 7p.BUL�4 T1 aN�
Zo Al
OU7LET SEPTIC TANK 3 z:o,�T' 9 ' �
-+Z. t: GRovA/D 14TER TAQLE,' Pam.N
/A/LfT OJSTR/B!/TWAl BOX. 3 FT ECTlON,CF
OtITLETD/STR/BUT/ON 60X f o F7 SEN✓AG�: D/SP. 0 A L SYST.E/►9
/lvtET t.�.acfJ/!vim o/T Fr. sTA�IlLAT/01V
L E..ACH110 P!T
D� . DIAm MuT. N ./1 FT
, D ISAI COY/TER/A o sc.�LE % ol�z.
FT
NUMBER 6F BEDROOMS 3 ' DIMENSION G ..4 /''r'✓
GI1RdAGED/SPOSALU/Y/. SDIL LOGS
SD/L'TEST
s TaTRL.EST/~TED FLOW 3 v G.4L.. -$O/L 7ZrST�2
s XUMBER GAF Y,C`AGIYI/VG`P/TS l I ECGY.. Z�Q EL Y. GATE GF SOIL TEST / ,/- -
i .5/O�,(,C-ACN!/vG OAR P/T:� � '- . lz i��y �•r�.
SQ, FT.. r RESULTS'h/JTNESSED dY ��D
_.^sotCOLAT/ON AArAr#/ .�ESs Ml /NCH.
? 407TOM lA4CN/NG JPER P/T S4• FT Lp ft
TOTAL LEACHING AREA'_ 3 s'p..FT. !i s✓ >So�L PY�RCOLAT/GNRATD 2, - MlN.�1NC141 .
RESERYEGEi4CN/N6 AR,EA_ SQ. FT. ` ¢
ti .5'O r LCk
i3ci.✓�Y M�v. .
a C r A IV c1 C:/< D
c / 4-0
ALS++_RT Y` ,f� ' R,C!$ RT s i ��N s•9t 0.
A. s�1 # �' AGE�:' Sf1.!✓D
mo st �: @�LORZVCrE k7I*IJVA //fit+ C
Nc.I0951 4 �' '.4 ti do tlt 37. o Lf/A 7 F
e`*�'�'nE�rr{6 E01y4f EL,. .8,0 _7J2 MAJN ,9T.� NYANN/9, MASS. ;.
9 Gi5 t ,,. 5
'`�sr, , �a� �� -a;, Ls:�a p . wOGl�ovnrp WATER EWCOt/NTERLcO !•L/ENT:/3.Ars/flE
�
GRO[JNO N/�fTER r4T ELEV. 0 A �iEl•T��- .�—:
JOB /1A�
f er!mi t -t;uribcr Datc 25 `�
_. .�..
f.omplc tpd by
— -
E
iI I CH CROUN1) WA1 ER LEVEL COMPUTAT 1 U1J
t Loca i'i on �� �c��: No
w
Sr e Lot � .
_, -
Owner: ,/t"/5/6,1 Address. .
Contractor. Address:
Notes: . _
STEP . l Measure 'depth -to water table: p
X.
} to nearest 1/10 ft , p/3,/g !
! gt
date
STEP : 2 'Using Water-Level Range Zone
u;
and Index Well; Map locate
site and determine:
A) Appropriate. index well
E
B) Water-level range zone R 1►i✓—
STEP ." 3 :Usrnj .monthly. repo"rt"Curr,en"t. t,
r° Water Resources. Condit ions" -'-'-
x Z3,determine current -dep.th Ao ° t
rye . water `level fo.r' rniiex .well i0/F --- -- , r `
4` Using Table of--Water-level )
Adju� mcnts for'- - - . --
� .. ,... � i r ndex` well
i
7STEP 2A� , 'current` depth to
water
level . for index well
f -(STEP 3) , and water-level :
zone (STEP 2B) determine
.water adjusime.nt . . . . . . . . . . . . . . . . 1
-
F
` STEP 5 . SEst ii�ate depth to high water
try =suti't rac,t l ng"Jile' wat er-
-
}ev:el adjustment (STEP, 4)'
4 t i'rom nieasurcd depth t.o;water
Y level at site (STE.P l) . . f
A—
E