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HomeMy WebLinkAbout0047 WIANNO CIRCLE - Health 47 Wianno Circle Osterville P A = 139 009 I I TOWN OF BARNSTABLE LOCATION T / ©G/1��� SEWAGE # f k4 6'�J VILLAGE fJ��L°1^�/r/r�`% ASSESSOR'S MAP & LOT C O INSTALLER'S NAME&PHONE NO. ,4rer V ZO 40#:6r SEPTIC TANK CAPACITY Z LEACHING FACILITY: (type) u ) Jrl�/1`L- NO. OF BEDROOMS q BUILDER OR OWNE efeT& � j PERMITDATE: �2 `�i��COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �f 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 ,�ty7 : y1 V3 ASSESSOR'S MAP NO. PARCEL L O C A T ION SEWAGE PERMIT NO. V I L L A G E I N S T A LLER'S _ NAME i ADDRESS I to ar h Sly�lr �S U I L D E R OR OWNER rb l�hti;. �als� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �e o � � � o ° r 3! � � a �i � '��\ / 3'�� ��� � Y P �� � I No. 6�Y� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppftcatton for Ot6pool bpotem Com5tructton 3permit Application is hereby made for Permit to Construct( )or Repair(i�)an On-site Sewage Disposal System at: Location Address or Lot No. !J �� � �J}G Owner's Name,Address and Te.N . Assessor's Map/Parcel ® q z�6—W `� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No./ e Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building 5 lrG No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow %l gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Aj swer when appl' able) 0 4l/ 1 j O® 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 AqXcHealth. .. Signed - _..... Date - IZA14� Application Approved by Date Application Disapproved for the following reasons Permit No. � Jt�O� Date Issued No. 0 tLJ fy✓O// Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS , ZIpprication for 30i5'ooal *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(V)an On-site Sewage Disposal System at: Location Address or Lot No. (,�7 /���/� G/�G Owner's Name,Address and Tel No Assessor's Map/Parcel 1 /O����v/i1� ~/���4r��%4; 7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 13or f�Gr��i`i Ca��� Type of Building: 1� Dwelling No.of Bedrooms 7 Garbage Grinder( � Other Type of Building P g ' NGC No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow 14_Al� gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations( swer when appl}'�able) //opt 10, 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�-so o Health. Signed Date / Application Approved by Date / Application Disapproved for the following reasons Permit No. Date Issued 12 ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS r" Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System ins led )or repaired/replaced(�),on by Installer �/ m Z ) CG'/!S 1 Lr'G�`/©`9 at 7 A1je7edj !"G C�O.g� I'/// s�' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Date 1 — {6 Inspector `�-1_ u THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. No. -------------------———"(Y®� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Diopoo, l OpMem Construction Permit Permission is hereby grante Ito AO1 to construct( )repair( )an On-site Sewage System located at No.# q 7 4/ ewee /4a e- Street and as described in the above Application for Disposal System Construction Permit. No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. _ - _ 7 Date: Approved by / Board of Health � - s YO S C6 f Iv 5 41 i l �- ' - -61L. w ; c is GZ$—Azl"ii l.c�., d c 1. Y r i �Jc e 0 8/18/2021 ShowAsbuilt(1700x2800) 'l tjwN Ur'BARNS I AB Lt LOCATION y G✓la�?'I�--lAde- SEWAGE N jd_ Yy VILLAGE fJ a If ASSESSOR'S MAP&LOT Q? OD INSTALLER'S NAME&PHONE NO. TIP/2OIO A/W 1 SEPTIC TANK CAPACITY J Dd H4� LEACHING FACILITY:(type) GJ-,S�b9o��C�xd ) SfdX.6'iYZ NO.OF BEDROOMS i) BUILDER OR OWNS .. CO/del _ PERMITDATE: �2 —�� COMPLIANCE DATE: 11-10 qS Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility sf" Feet Private Water Supply Well and Leaching Facility(It any wells exist on site or within 200 feet of leaching facility) q Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i. yrY l RdtrY .. �e awt f'f sf S V3 , https://itsgldb.town.barnstable.ma.us:8431/Home/ShowAsbui It?mp=139009&sq=1 1/1 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems .Only. CERTIFICATION OF SKETCH AND APPLICATION FORA DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal-works construction permit signed b me dated 1 /. A-10p g y l� , concerning the property located at 7 4/47/e'Y'�P G*1de meets all of the following criteria: ere are no wetlands within.300 feet of the proposed septic system There are no private wells within 156 feet of the proposed septic system he observed oundwater table is 14 feet or greater below the bottom of the leaching facility � g g ere is no.increase inflow and/or change in use proposed There are no variances requested or needed. SIGNED: DATE: / LICENSED'SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER f [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIIt_ONMLO=ENTA'^-P�tOTECTIO �,//�yayR�CEL OCT 2 5 2004 � LOT TOWN OF BARNSTABLE HEALTH DEPT.. LLJ TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURTACE SEWAGE DISPOSAL SYSTEM FORM 'f? PART A ' f CERTIFICATION k , ` ;! Property Address: AdA�.. Owner's.Nam t Owner's Address: 7 6aA o a(-76 Date of Inspection. Name of Inspec lease print y� �►"T��o Company Name Mailing Address: Telephone.Number: :. . CERTIFICATION STATEMENT, I certify that I have personally inspected the sewage disposal system at this address and that the information repnrted 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 flinction 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 Needs Further Evaluation by the Local Approving Authority �kia i 1 c 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 3 0,000 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 �s ****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 INSPECTIONIORM PART A kV7 CERTIFICATION-(continued)Property Address: r l Owner a, Date of Inspection: ,L, Inspection Summary: Check A,B,C,D or E./ALWAYS complete.all of Section D. A. System Passes: V I have not found_an.•information which indicates that an aii y of the f uure criteria described m I0 C Y � MR 15303 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 es'no or not determined Y N ND in the for the following "Y m statements. If ot'dete( ) n nnined lease explain: P The septic tank is metal and over 20 years old*or the septic tank(wheiller metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tan]: 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.re uired pumping more.than'4 times a year due to broken or obstructedpipe(s .The system will 9 P P g Y Y pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain:: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUB SURF ACE_SEWAGE DISPOSAL SYSTEM INSPECTION FOIbM PART A CERTIFICATION'(continued) ) ��i . Property .dress: L/.e/, l __ Owner: 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 public health,.safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR15.303(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 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 dress: j Owner. Date of Inspection: 7,aCXj 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 V 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. V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface 1/ 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.] . (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as -149 described in 310 CMR 15.303,therefom 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• 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 1I of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant tlueat,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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:B CHECKLIST Property ddress: Own Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the.followine: Yes Pumping.information was provided by the owner, occupant,or Board of Health Were.anv of the system components pumped out in the previous two weeks _ V Has the system received normal floes in the previous two week period ? V 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 constniction,dimensions,depth of liquid,depth of sludge and depth of scum? t/ :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 ono 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 Page 6 of 11 OFI+ICIAL INSPECTIONFORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM PART C SYSTEM INFORMATION Property Address:_ ( //L Owner: _ T~! Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . . Number of bedrooms(actual): DESIGN flow based on 310 CIvIR 15.2,0,3 (Aforexample: 11.0 gpd x#of bedrooms): Number of current residents: Does residence.?- ve a garbage grinder(yes or no): Is laundry on a separate sewage system (y s or no):,G(/ .[if yes separate inspection required] Laundry system inspected es or no):/�110 Seasonal use: (yes or no): Water meter readings; if a i able(last 2 years usage(gpd)): Oz`A7,,aoy 03---Z;200 Sump pump(yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL. 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: OTI�IEII(describe): GENERAL INFORMATION Pumping Records. Source of information: Was system pumped as part of tl e inspectio (yes ro):_a If yes, volume pumped: gallons How was quantity pumped determined? Reason Tor pumping; TYP ,`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 copyof the DEP,approval —Other(describe): roxiniate a e of all con�aponents,dale installed(ifla�own) andsource of information: fog• �[�- �� Were sewage odors detected when arriving at the site(yes or no 6 Paee 7 of I 1 ` OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: k1A&/XP Cy v Owner Date of Inspection: (� BUILDING SEWER(locate on site plan)�,Z Depth below grade: Materials of con stn.i cti on:, 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: 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: f ,k Sludge depth: Distance from top of sludge to bottom of outlet tee or 6affle: Scum thickness: Distance from to of scum to top of outlet tee.or baffle: Distance from bottom of scum to bottom of outlet tep_or baffle: How were dimensions determined: Vht J _p. Comments (on pumping recommer>6ations, inlet and outlet tee or baffle condition,structural integrity, liquid levels ,as,related to outlet invert, eviden e of leakage, etc. GREASE TRAP,.J�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 Page 8 of 11 OFFICIAL:INSPECTION DORM NOT FOR VOLUNTARVASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:C Owner• Date of nspection: TIGHT or HOLDING TANKU. (tank must be pumped at time of inspection)I(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 alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level'above outlet invert`?jak,(A '' &ke j _. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of kage into pr out of bo e .): J6 Al ,� ' PUAIP CHAMBElj�i�(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 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECCTION FORM PART C SYSTEM INFORMATION (continued) Property Address: V7 �1),A,1,,19�4;h Owner / Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type, leaching pits,number:_ eaching 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.)* y___ ` 1 � CESSP00%(cesspool must be pumped as part of inspect ion)(]ocate 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 constriction: . Indication, of groundwater iafiow(yes or.no): Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIM'. (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 I] OFFICIAL_INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL-SYSTEM.INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: r �� Date of nspection: 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. 1 h s� L 10 Page 1 l of 1 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: 7 / W Owner: L`--. Date of Inspection: 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 excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the hi-gh ground water"elevation: d 11 .......... a,i)A. At IWA e6 an"ll/,m.,Vc, Permit Number: . Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 7 [ Lot No. Owner: k-rum Address: Contractor: �[��/� � ._��, v Address: Notes: ,tli'°e/� � �s, v��S STEP 1 Measure depth to water table �1 to nearest 1/10 f+ Date /cd/ C month/day/Year i STEP 2 Using Water-Level Range Zone and Index Well Map locate w site and determine: % OAppropriate index well.................................................... OWater-level,range zone ..........:.......................................... STEP.3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water level zone (STEP 2B) determine water-level adjustment ...................... STEP 5 Estimate depth to high veater by subtracting the water level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .......................... l/•✓` Figure 13.--Reproducible computation form, 15 16X /4 DE CK • _ e II BEDROOM I do KITCHEN DINING 1I, NA IF-wA\L - 2 2� FCtC� 16e T HALL 66g 2 bg 2 cG a ' BATH 1 0 BEDROOM 2 + LIVING RM q ^ DN UP Cl - - ✓� lie\�G vENEE2-_ - - 1 MS LYNDA ROWLAND APPROVED BY: DRAWN 9Y . . DATE: 11•L3.0V REVtBED EXISTING 2ND FLOOR . - ORAWWO NYMBEA . 47 W/ANNO CIRCLE E- 1 vast 'gun®a�w.�ma ar�mvantr. - i r i F _-_-__ --__--- -- _ _ -_ __ - - - ----- — �� �• i i GAME RM UTILITIES ll D — 61. HALL IJ CLOs. BEDROOM 3 BATH 2 FAMILY RM. ' - IIe,GC YEN EE2 MS LYNDA ROWLAND . SCALEC Ike••— I• APPROVm BT: ^ OMWN@Y GATE: 11•23'O•/ REVISED - EXISTING I�FLOOR WO NUMBER 47 WYANNO CIRCLE ORAW — 2 • ��tL Nufl®OM MI.RO01 G[Al11NRR� j - • � I j . - NEW IirawDRhtL _18• Stt>=LF ON ROP OF K.NCE I 'PANCL _ �— wALL_ - B2ACLETS IF 0.E 6L, SOAPSTONE SII,¢ A,TOP - � MEW I SINGLE SHED-F /<�6OVE - 1+AN0 wail .I. - NEW PAPIn T10N HA. .e.. .. 0 ...�.. _ - .... _ - ND LOSET ^r• ..-,.._._. .._ -_. - - ____.__ -.- ..._:�.._....... , .�-a� -. ?b AlL F1esT FLwR-G LxeT Dcou� l ... a- I1- I�, ._e....1. ' ..., - - IN,-,PROUND Kt�TING. ..� ,..DOOCS TO Er PhNEt_ PN I3I. 6oiLti . .. - �.._.-"-•„-:.-. .. ,. LA LLl.._GOLlJ M1.IS.. .-. � �- -"t W ,�.:.. � .�� ..� .•�SNSVI•ATE,.A E.:POP.E D..Eic['E2101_:WALL$:. M.P.. WNOLe .. _ ... ELECCRIC-._:['?6TESC —� ,_�..,...._. .. _ r_a.�w......i. - _. .. - - - n� -,.... i¢-Cori wTl'oNeI+G'T'oHOULE � •-.�,• .�-....•,. .. . �:s'VHNGEfz� PLASTE R'•.FO2 RLL NC-v/. WORK ... ..w:....+++....»�--.�. _•a. .. 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DA!TH - Ll Vl N6 ' RMLNEW MHHOVANY DOOV- EEW FIAL.F WAL\- S6OIMENLIU\+S AL'E VCQIFI.ED IN THE FIEtg NEW PALTITION - I MS LYNDA ROWLAND SCALE: I�y•• 1' APPROVED By: DRAWN BY Q,'C DATE: 11•`l•OY - REVISED 1.7_'1 0S- PROPOSED 2No FLOOR - DRAWING NUMBER 47 WIANND CIRCLE A. — 2