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HomeMy WebLinkAbout0214 PITCHER'S WAY - Health 214 Pitcher's Way .i 289-033 Hyannis/ r' M { W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out `„� forms on the ==//.lCJ//�-7 computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name t 443 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority lzl�jS October 17, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the . report to the appropriate regional office of the DEP. The original should be sent to the system,owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 _ 4 Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,nM 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 214 Pitchers Way Property Address Jumar Barbosa Owner Owners Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 214 Pitchers Way M Property Address Jumar Barbosa Owner Owner's Name informatics is required for y Hyannis MA 02601 October 17, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 214 Pitchers Way M Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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 0 ❑ 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. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Citylfown State Zip Code Date of Inspection C. Checklist 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: ® ❑ 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: not determined Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 210 gpd 9 ( Y 9 (gpd)): Detail: 2006-2007 Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 8+years. Certificate of compliance issued 4/10/2000 (Board of Health permit#2000-204) Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 ft x 6 ft x 5 ft(1500 gallon) Sludge depth: 4 in t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 2 In Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? As Built Card Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins-09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 214 Pitchers Way M Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears level with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/OE Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 214 Pitchers Way M Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 18 inches below the top of the leaching gallery. Cesspools (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 ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Barnstable GIS Department records ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is 20 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 5'r 214 Pitchers Way Property Address Jumar Barbosa Owner Owner's Name information is required for Hyannis MA 02601 October 17, 2008 every page. Citylfown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION /1 i�t N ,tS p � SEWAGE # -VILLAGE ! All ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK APACTIY LEACHING FACILITY: (type) NO. OF BEDROOMS S (size) BUILDER OR OWNER PERMITDATE: O 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) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) I Furnished by Feet i i 1 4 IL d r „pper� �N COMMONWEALTH OF MASSACHUSETTS -7 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . 2 DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 214 Pitchers Way Hyannis Owner's Name: Deborah Cani zales Owner's Address: RECEIVED Date of Inspection: Name of Inspector:(please print) Wi 11 i am E_ •Robi_nson Sr. JUL 222004 Company Name: William E. Robinson Septic .Service TOWN OF BARNSTABLE Mailing Address: P O BOX 1089 HEALTH DEPT. Centerville, MA Telephone Number: (508) 775-8776 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 CNIR 15.000). The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails � Inspector's Signature: , ,,i� �f,,,�► ,�'.” Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of 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 seat 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)- �Poperty.Address:214 Pitchers Way ' Hyannis O,wfi r Deborah C nizal s .��Date of Inspection: t- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys tin Passes: 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. stem Conditionally Passes: 4 ne or more system components as described in the"Conditional Pass"section need to be replaced or repaire The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, khibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicati that the tank is less than 20 years old is available. ND ex ain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obs cted pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app oval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND ex plain: The system required pumping more than 4 times a year due to broken or obstrtKxed pipe(s).The system will pass'11 spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is arnond N ain: Pag-3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 214 Pitchers Way _Hyannis Owner: Deborah- Canizales Date of Inspection:: 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 fail' to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s tem 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. Syste will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is unctioning in a manner that protects the public health,safety and environment: _ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfac water supply or tributary to a surface water supply. e system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. he system has aseptic 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 Prod l a pr ate water supply well** Method used to determine distance 'This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform cteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fai ure criteria are triggered.A copy of the analysis must be attached to this form. i 3. Oth r: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART A CERTI FICATION continued Property Address: 214 Pitchers Wav Hyannis Owner: Deborah Canizales Date of Inspection: D. S stem Failure Criteria applicable to all systems: You mu t indicate`)+es"or"no"to each of the following for all inspections: Yes N 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 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%-Ater supply well with no acceptable water quality analysis.(This system passes if(lie 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(his forma (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. La a Systems: To be c nsidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You mu t indicate tither"yes"or"no"to each of the following: (The fo owing criteria apply to large systems in addition to the criteria above) yes n 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 We Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you h ve answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in ection D above the large system has failed.The immer or operator of any large system considered a significan threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.T e system owner should contact the appropriate regional once of the Department. II 4 f Page S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 214 Pitchers Way Hyannis Owner: Deborah Canizales Date of inspection: 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 t/ 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 baffffles 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. y _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance. is unacceptable)[310 CMR 15.302(3)(b)] S Page 6 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 214 Pitchers Way Hyannis Owner: Deborah Canizales Date of Inspection: ~G'/ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .'/46 D Number of current residents: Does residence have a garbage der(yes or no): k 0 Is laundry on a separate sewage system(yes or no)v/b [if yes separate inspection required) Laundry system inspected(yes or no): � Seasonal use:(yes or no):/ U Water meter readings,if available(last 2 years usage(gpd)): May 03 to 04 90,750 Sump pump(yes or no): May 02 to 03 95, 250 Last date of occupancy: COMM CIAL/INDUSTRIAL Type of es blishment: Design flo (based on 310 CMR 15.203): gpd Basis of de ign now(seats/persons/sgft,etc.): Grease tra present(yes or no):_ Industrial aste holding tank present(yes or no):_ Non•sani waste discharged to the Title 5 system(yes or no):_ Water m er readings,if available: Last dat of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: &..1. Was system pumped as part of the inspection(yes or no): iEJ If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE SYSTEM _ eptic 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 contact(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, Were sewage odors detected when arriving at the site(yes or no): 6 I I'agc 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 214 Pitchers Way Hyannis 0waerD-eborah Caniza1es Date of Inspection: f, =j C4—6 tl BUILDING SEWE (locate on site plan) Depth below grade Materials of cons ction:_cast iron 40 PVC_other(explain): Distance from p vate water supply well or suction line: Comments(on o dition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: 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: / < G Sludge depth: ` =— 3 3 3 Distance Gom top of sludge to bottom of outlet ice or baffle: _ Scum thickness:-;L=3 Distance from top of scum to top of outlet tee or baffle: � Distance Gom bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:_ © jyj:5�w e, , /L Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert evidence of leakage, dLy n GREAS TRAP:_(locate on site plan) Depth bel w grade:_ Material o construction:_concrete._metal fiberglass_polyethylene_other (explain): _ Dimension Scum t tic ess. Distance fr top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Dale of last umping: Comments on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t( outlet invert,evidence of leakage,etc.): 7 Page 8 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 214. Pitchers Way Hyannis Owner: Deborah Canizales Date of Inspection: TIGHT or H DING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gra c Material of cons( ction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: I gallons Design Flow: allons/day Alarm present es or no): Alarm level: Alarm in working order(yes or no): Date of last pu ping: Comments(c ndition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CN AIi MBER: (locate on site plan) Pumps in working or er(yes or no): Alarms in working o der(yes or no): Commcnts(note co dition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9ofIi OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 214 Pitchers Way Hyannis Owner: Deborah Canizales Date of Inspection:_ ./ter-6 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,cxcavation'not required) If SAS not located explain why: Type }aching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): a 0 „ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and config tion: Depth—top of liquid inlet invert. Depth of solids layer- Depth of scum layer: Dimensions of cesspo Materials of constructi n: Indication of groundw er inflow(yes or no): Comments(note condi on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (loca a on site plan) Materials of construc ion: Dimensions: Depth of solids: Comments(note cond tion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 214 Pitchers Way Hyannis Owner: Deborah Canizales Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. / ► r f 1 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 214 Pitchers Way Hyannis Owner. Deborah Canizales Date:of Inspection: —C� 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 ISO feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water eleva ion:_ �-es S •� : 5 � U s l � o�..� at , t 11 aD• ct • o t•0. �' O 4 crJr. WMAIN ST All pI . rjr 0 :SB?4 70.96, O� ' i6�ia N� -0/2720 .' 14 �p Q o /9 V a; :Z- c pp .o a1 ZZ eon i,b. Sub,ivisit n o ' Lot �l Shown on Kan 22825 16236 piled �rit� Cart- of 'title so. Registry District Of amrnstable County ,' , r C�rtil e�tg'S of t, t may to ls$veo or ld.')d ion �s_ �y./ ,.�, _ �,--- - ------ moo` aft tat cowt. TOWN OF BARNSTABLE LOCATION / SEWAGE # VILLAGE 6' " ' ' /l ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 2 ZS—L724 SEPTIC TANK CAPACITY /�6—O LEACHING FACILITY: (type) ' L `;C (size) NO. OF BEDROOMS S j BUILDER OR OWNER �- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet isPrivate Water Supply Well and Leaching Facili ty (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 71- I i J" I y t \, /' }p - ►_ )'TO WN OF BARNSTABLE LOCATION z r l he ' SEWAGE # �� m' Y VILLAGE ASSESSOR'S MAP & LOT [?..®� INSTALLER'S NAME&PHONE NO. ii�-3a ' '? SEPTIC TANK CAPACITY LEACHING FACILITY: (type) .;-- 47 L e� (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: d COMPLIANCE DATE: Cal— O -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 �� � n I� a.�.� � W r f : � h_ C . lfAf3 t� No. �"— Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 01ppYication for Migoml *p5tern Construction Permit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 214 Pitchers Way, Hyannis Jean Ryan Assessor's Map/Parcel The C ha l e t , 35 Chastellux, Newport In t ler's Name,Addr s,and Tel.No: Designer's Name,Address and Tel.No. 1 Vm. E. Rotinson Sehtic Service PO Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 2/3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Per ns Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons," r day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system consisting of a tank, D-box and. 2 concrete chambers with stone all around.. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by thi oar of Health. _ � Signed Date Application Approved by4­71 Date Application Disapproved for the following reasons Permit No. Date Issued �M/) 6 No. - Fee t 50 J THE C.PMMONWEALTH OF MASSACHUSETTS Entered in computer: -PUBLIC HEALTH DIVI ION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes Application for ;Digpogaf *p!gtem Con!Aruction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 214 Pitchers Way, Hyannis Jean Ryan Assessor's Map/Parcel The Chalet,35 Chastellux, Newport Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 2/3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title �_. Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alteration (Answer when applicable) _ Title-5 septic system consisting of a tann l�bgx and 2 concrete chambers with stone all around. , .i Da)ast i spected: Agreement: The undersigned agrees to ensure,the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this oar f Health. Signed Date L ` Application Approved by Date D Application Disapproved for the following reasons An r Permit No. ' Date Issued t" 3 THE COMMONWEALTH OF MASSACHUSETTS L1ya} -``x� BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO R Ili~thht the On-site Sewage Disposal System Constructed( )Repaired (X )Upgr d d( ) Abandoned(` )by m. E. Robinson Se tic Service at 214 Pitchers Way, Hyannis has be n constructed in accordance \ with the provisions of Title 5 and the for Disp!osallSystem Construction Permit No. dated Installer Wm. E. Robinson Sri. Designer /,_`,�\ r _l The issuance of this pe t shall not be construed as a guarantee that the sys��will function as desk gned� t,10241114��4 Date ... .T v v l�L �9d1►1 � � Inspector ,n j ——— /—'} —— ———————————————————— ———=———— No.At 1 � t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ► RyanMie;potar *p�tem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 214 Pitchers Way, Hyannis . and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction u t be c,m�pyleted within three years of the date of thi Date: / / F Approved by } NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. _ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) Y William E . Robinson,5 rhereby certify that the application for disposal works construction permit signed by me dated <1~3 �� , concerning the property located at 214 P i t c h P r s Way, 44srann=s meets all of the Mowing criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch. There are no wetlands within 100 feet of the proposed septic system _ There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will Mt be located less than five feet above the maximum adjusted groundwater table elevation: (Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed teaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX High G.W. Adjustment __--— DIFFERENCE BETWEEN A and B SIGNED : �: � - V " DATE: _ [Sketch proposed plan of system on back). y:heath folder:cen r ,. .� ^-- �� `\ ti '� Y�