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Home My WebLink About0012 HICKORY HILL CIRCLE - Health 12 HICKORY BILL CIRCLE OSTERVILLL A 120 057 f TOWN OF BARNSTABLE . � LOCATION !.� /� �/'� c��• SEWAGE #d&6 I VILLAGE_ S �. -------------- 1 _ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACMITY: (type)-- —' (size) NO. OF BEDROOMS - .w BUILDER OR OWNER W 7- I PERMIT DATE: ,:� �� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bot of Leaching Facility Feet Private Water Supply Well and Leaching Fa tY (If any wells exist on site or.witWn 200 feet of leaching f ility) Edge of Wedand and Leaching Facili any wetlands exist Feet J --within 300 feet of leaching facility) I Furrushed,b Feet a Y e F s i .. S / I cAl .�' V .. TOWS OF BARNSTABLE LocArlort 1 a -1�-�`1 SEWAGE # 00®a VILU GE ®t3 J �`�• ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. btt SEPTIC TANK CAPACITY I L;ACHING FACILITY: (ty. ) y -2.L LC.(size) 1'5" 25'- 2 NO.OF BEDROOMS BOLDER OR WNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ;on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Famished by r ' 1 t i 6 �• v r' � ,E �= �'- i3-17 r TOWN OF BARNSTABLE LOCATION SEWAGE #dC6—3 VILLAGE C�S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) .� •� "� NO. OF BEDROOMS__ EbILDER OR OWNER 11V V ' .* PERMTTDATE: �� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bot of Leaching Facility Feet Private Water Supply Well Leaching Fac' ty (If any wells exist on site or within 200 feet of leaching f ility) Feet Edge of Wetland and Leaching Facilit�yr( any wetlands exist within 300 feet of leaching facility), Feet Furnished by ��- i ,�� ,�- i � . . � �, �� .�- . N� ��a �a � � �' --� v.. a y ,. � �4 J + t; - . - _. '�. � •� ��. 1,+y� ! � \\\ .\_ k - 1 1 No. lv y Fee 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS V 01pplitation for �Digoar 6petem Com5truction Vermtt Application fora Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 12 Hickory Hill Circle Hyyti Assessor's Map/Parc 1, OSter-\ulle Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 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 Alterations(Answer when applicable) Title-5 septic system, consisting of a tank, n—hoy and 2 nnnnrat-a 1 aanh nhaM.hers With Stc)n_e all ar-g1AnC] 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 issued by this Board Health. Signed Date �—��ati Application Approved b Date 'er- �-- 2� Application Disapproved for the following Qsons Permit No. Date Issued n ��,� ———————— — — ------ — `NNo. C/ l �+ 5 O Fee r , THE-,COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ` 2pprication for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System ❑Individual Components Lo !c or4AlC lino y ill C ire le Owner's Name,Address and Tel.No. 1G n Oster e Hyyti Assessor's Map/g � g ler' Je A dress,and Tel. o. f t . Designer's Name,Address and Tel.No. " gym. todbinson eptic Service P 0 -,Box 1089, ,Centerville Type of Building: Dwelling . No.of Bedrooms 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 A; Size of Septic Tank Type of S.A.S. Description of Soil i Sand. r Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system, consisting of a tank, D-box and 2 concrete leach chambers with stone all around.. Date last inspected: •' �w 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<beeri issued by this oar Health. Signed 1 Date ' Application Approved b ' -l.L.�t.4-t.✓� C±rf1 ' Date Application Disapproved for the following reasons `! Permit No. Date Issued ------------ THE.COMMONWEALTH OF MASSACHUSETTS Hyyt i BARNSTABLE, MASSACHUSETTS f Certificate of Compliance THIS IS TO WTIK,Y,tl�t t$e.On-site S wa Disp al S stem Constructed( )Repaired( X)Upgraded( ) Abandoned( )by o ins on. Me'�%Tc er�iice at 12 Hickory Hill Circle, Osterville 0 has been constrgcted it,,a r e with the provisions of Title 5 and the for Disposal System Construction Pe dated. Installer Wm. E. Robinson S r. Designer J ,j /V n The issuance of this permit,�}'a not be cons. ed as a guarantee that the s :tem �11�unctio as ddesigned Date �! r Inspectorf'/ No.��Y�/'"' /�------------------------Fee $50— THE COMMONWEALTH OF MASSACHUSETTS Hyyt i PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 12 Hickory Hil] Circle, sterville 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:Cons ction must becompleted within three years of the date of a it. ' Date: ,Approved �� r 116/" 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 PERMrf(WITHOUT DESIGNED PLANS) ), W i l l iatn E. R ob ins on,5 Riereby certify that the application for disposal works construction permit signed by me dated G 8! 6—G--?i , concerning the property located at 12 Hickory Hill Circle , Osterville meets ail of the following criteria: ` •, The.Wed system is connected to a residential dwelling only. There are no commercial or business a�iated with the dwelling. • The 1 is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ere re no wetlands within 100 feet of the proposed septic s'ystent ere are no private well,within 150 feet of the proposed septic system, e is no increase in flow and/or change in use proposed • ere are no variances requested or needed. The bottom of the proposed leaching facility will rat 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 leaching 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) r B) G.W.Elevation +the MAX High G.W. adjustment DIFFERENCE.BETWEEN A and B 33 SIGNED : e 1, ` DATE: [Sketch proposed plan of system on back[.' +health folds cent L p CO�L11O\'ti��.�I,TH OF MASSACHL;SETTS _ EXECUTIVE OFFICE OF E:N'VIRO\:1IE.TAL AFF_AJRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ip Z�-TER ONE� STREET. BOSTON 1',Lk 0210� t6)-j 292-550L, TRUDY COL Secretan ARGEO PA[:L CELLLCCi DAVID B STP.-'HS Governor Cotnnuss:onec SUBSURFACE SEWAGE DISPOSAL SYSTEM MISPECTION FORM PART'A CERTHWATION Property Address: 12 Hickory Hill Circle Name of Owner Eleanore Hyyt O s t e ry i l l s Address of Owner: Date of Inspection: Nameofinspector:(PleasePrint)WM. E. Robinson Sr. I am a DEP approved s errl inspector to Section 15—W of Title 5(310 CMR 15.000) Company Name: Wrc E . Robinson Septic Service MadingAddress: PO BOX 1069, Centerville MA - Telephm Number: CERTIFICATION STATEMENT 1 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 isposal systems. The system: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: iC/Y Date: -(� r The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design fiow 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 10 � - •a �ECEIV�� S EP 8 2000 t � ►EALTHppri retiseQ Paptiorll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A CERTIFICATION(continued) ' 'rowerty pAddress: J 12 Hickory Hill Circle, Osterville Date of Inspection: Hyyti INSPECTION SUMMAR Check A B, C, of D: A. SYSTJ�II PASSES: 1 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. Indicat yes,no, or not determined(Y. N,or NO). 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 H 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 pipets) 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 pipets). The system will pass III inspection if(with approval of the Board of Heahh): broken pipets)are replaced obstruction is removed revised 5/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Hickory Hill Circle, Osterville Owner: Hyyti 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 failing to protect the public health, safety and the environment. I SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 C1iIR 15.303 11)(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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 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 z Y r revised Page 3of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Hickory Hill Circle, Osterville Owner: H y t i Date of Ins � U' D. SYSTEM FAILS: You m t indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct.the failure. Yes o Backup of sewage into facility-or system component due to an overloaded orelogged 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 112 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 privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 100 feet but greater than 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. LA E SYSTEM FAILS: You mus indicate either "Yes" or "No' to each of the following: he following criteria apply to large systems in addition to the criteria above: �he 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: I l 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 own er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o the Department for further information. revisAQ c/L/9c PaRc4ofII j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Prop"Address: 1 2 Hickory Hill. Circle, Osterville Owner: T�`'�`c',�{- Date of Inspi " i Check if the following have been done: You must indicate either "Yes- or "No" as to each of the following: Yes j No Pumping information was provided by the owner, occupant, or Board of Health. V _ None of the system components have been pumped for at least two weeks and the rystem 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. As built plans have been obtained and examined. Note if they are not available.with NVA. 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 condition 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 an of the failure criteria► I Y related to Part C is at issue, approximation of distance i i s unacceptable) (15.302(311b)] P _ The facility owner land occupants,if differeru from owner) were provided with information on the propermaintenaarAi.-0f SubSurface Disposal Systems. re. _sec 9j2/98 PaRc 5 of 11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Iropeny Address: 1 2 -Hickory Hill Circle, Osterville Owner: Hvvti Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: e�Q g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual):- Total DESIGN flow 1, 6- Number of current residents: Garbage grinder)yes or no): X— p Laundry Iseparate system) (yes or no118 If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no)�Az 0 Water meter readings,if available (last two year's usage(gpo): Sump Pump(yes or no): I(-,- r Last date of occupancy: /7- .1998 41 , 000 gal. COM: ERCIALANDUSTRIAL: Type establishment: Design low: qpd ( Based on 15.203) Basis of esign flow Grease tr p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-senit ry waste discharged to the Title 5 system: (yes or no)_ Water m er readings, if available: Last date of occupancy: OTHER-(Describe) Last of occupancy: GENERAL INFORMATION PUMPING RECORDSd source of information: System pumped as part of inspection: (yes or no) s�, If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM , 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) VA 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: Sewage odors detected when arriving at the site: )yes or no) �eviseu 9 2 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM( PART C SYSTEM INFORMATION(eondrr ) 'rop"Address: 12 Hickory Hill Circle, Ostervill'e Owr►er: HV 1 Date of Inspemon: BUM IN SEWER: (Locat on site plan) Depth elow grade:_ Materi of construction:_cast iron_40 PVC_ other(explain) Distan a from private water supply well or suction line, Dia ter Com ents: (condition 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_ (sage confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: r i Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: f Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: ,,yam iy� ;omments: (recommendation for pumping, condition of inlet outlet tees or baffles,depth of liquid level in relation iss outlet invert, structural integrity, evidence of leakage. etc.) �.o , ► /.1' J j e .� 3d m1 GR E TRAP: (locat on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass._Polyethylene_otherlexplain) Dimensi ns: Scum thi kness: Distance rom top of scum to top of outlet tee or baffle: Distance rom bottom of scum to bottom of outlet tee or baffle: Date of I st pumping: Comme ts: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evident a of leakage. etc.) Page 7orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 1 2 -Hickory Hill Circle, Osterville owner: Hyy��ti Date of InspectfoA: T1G OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Ilocet on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass_Polyethylene other(explain) Dimensi ns: Capacit gallons Design ow: gallons day Alarm resent Alarm evel: Alarm in working order: Yes_ No_ Date f previous pumping: Com ents: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert.— Comments: Inote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (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.) rev1Se6 5/2/SC Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 12 Hickory Hill Circle, Osterville Owner: Hvvt1 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_V (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:_ leaching chambers,number:,2, leaching galleries, number:_ leaching trenches. number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soilgns of hydr lic failure, le el of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: ' )epth of scum layer::— Dimensions of cesspool Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comm is: (note c ndition of soil, signs of hydraulic failure, level of ponding• condition of vegetation, etc.) + PRITofsolids: +_ ,(locate plan) Matonstruction Dept Dimensions: Comm nts: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION feontinued) Nap"Address: 12 Hickory Hill Circle, Osterville lwner: ante of Inspe V.y t 1 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) ` . �p G . l R rev-sec 5;'2/9E PaKc10ofII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION(continued) ropwty Address: 12 Hickory Hill Circle, Osterville' Owner: 1 Date of Ins = NRCS Report name Soil Type_ Typical depth to groundwater uSGS Date website visited Observation Wells checked Moderate Deep Groundwater depth: Shallow 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 Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) rev_strC 9/L,�95 PaFcuoru