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0059 RIVER RIDGE DRIVE - Health
59,--RIVER`RIDGE WJ.P, MARSTONSMILLS A' = GI Li egoTOWN OF BARNSTABLE LOCATION A SEWAGE #. VILLAGE ;_. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. , SEPTIC TANK CAPACITY LEACHING FACILITY:(type)� ( k (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER_� �� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes _No ' / ' : r ,,,r �,1 1° �, �, o �� �� t� �' ' �. C� � .tea � �� � . ��� �� �� � � �% • L,(C_,. �. :.. J 5gor®o � � l No...��,-��z a � � FPS.. ......_ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Diipnsa1 Vork,5 Tomitrurtiun Frratit Application is hereby made for a Permit to Construct (L4 or Repair ( ) an Individual Sewage Disposal System at- � .0.. .. ......... .... -••---• �-. ............................................................... Lo io •Address t No. vv\\'// .. - v .............................................. O ner Address Installer Address Type of Building Size Lot.....l..a................Sq. feet .-� Dwelling—No. of Bedrooms......_Jam...................................Expansion Attic (F^D) Garbage Grinder eo) a`4 Other—T ._. ype of Buildin g �✓�"''�--No. of persons:........................... Showers ( ) — Cafeteria ( ) d Other fixtures ...................................... Desi n Flow---•-•-••---•---l-/-�----• �--------------- W g gallons per psen per day. Total daily flow..................._................._....._gallons. WSeptic Tank—Liquid capacity./�v.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area....:.............sq. ft. Z Other Distribution box ( ) Dosing nk ( ) aPercolation Test Results Performed by-- .............. ................................... Date.......�0� l_ ............ a Test Pit No. 1_._. ...minutes per inch Depth of Test Pit.................... Depth to ground water...Al_____.��...- �%4 Test Pit No. 2................minutes per inch Depth of.Test Pit---_................ Depth to ground water........................ Descriptionof Soil........ ----------------------------------------------------------------------------------------------------------------------------- U ----------------------•-••-•••-----•----------- --------------------- ----------------------------•-•------------•----------------------------•------•--------•------------------------------------------ W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ......_...••----------••-•••-•-----...••---------•••-----•-••••---------•••----------------------------------•-----•--------•---•-----••---•---------•-------•-••----•--------_....•-----•-----.....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co fiance has been issued by the board of health. Signed .-- 6—A47 ------ ----�� 5'............. Application Approved By ............. ........................................ d--�l?..� Dare Application Disapproved for the following reasons- ----------------- -------------------------------------------------------------- ------------ -------------........I............ qqDace Permit No. --------. -&-.10.17---------------- -------- Issued .................... - Dace No.....�f-�_-44 ® J`� "'(rJ� '� vl Yuic .. i`).{ .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSt?ABLE I"�"tom` • App iratinn for Dhipug al Works Tomitrnrtion ramit Application is hereby made for a Permit to Construct (1,1_�Ior Repair ( ) an Individual Sewage Disposal Sy _. �... ----------- �'Ll-_ ......................................•-- o ion^-Addre;; Lot No. rl ( - . A. Owner "•")�� _--_ Address � Installer Address �� / n„ Type of Building Size Lot__________s................Sq. feet U Dwelling—No. of Bedrooms-------��________________________________Expansion Attic (.*°v) Garbage Grinder Other—Type of Building of persons____________________________ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------• -- _ .............. �_� _________gallons per .e-se per day. Total daily flow_.____._._� U W Design Flow g P P P Y Y ..................................gallons. WSeptic Tank—Liquid capacity_1��_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.............._...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ ' / / Percolation Test Results Performed by.. _ •---------------- Date ��f �ll01v� Test Pit No. 1.__.�a- ----minutes per inch Depth of Test Pit____________________ Depth to ground water_____._.__.._.____._.__. frq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_._.___.._..___________- 1:4 --y x . Description of Soil-------a ... �� 1�___'-----------•---•-••----•---------------------------------------•--------------------------•------------- V ---------------------------- -------------- •------- ••----- -•-------------------------- •-•••-------------- •--------------------------- ------------ •------- -----------------------------•--••-------------- W UNature of Repairs or Alterations—Answer when applicable............................___._____._.__..___.._.___________.._.______....._._______________.. ---------------------------------------••--•--------------------------------------------------_._...--•-----••--•-•--•---•----------••••----•---••-•-..................-............................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signedr. -----�—.- .............................. -- Dfre Application Approved By .............. ...Z --'�. ..-.-.....--... .................... -------- Date Application Disapproved for the following reasons- - -------- ------------------------------------ --------------------........................................................ .............................................................. ---- -------------------------- ------------------------------------------------------------------- -----------.................. --------------- - qq -----------------------Dare PermitNo. -----.-.1.a �O I--7............................ Issued ------- ...............................---------- Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ` Certificate of Compliance THIS IS TO CERTIFYThat the Individual Sewage Disposal System constructed ) or Repaired ( ) by-�. . ..... ----------------------------------------------------------- -------------------------------------- ------------------------ --------------------------------------------------- Insraller at ........ .... -- .. .....:... ... -J-----------------��. -------------. ....--.-...-...-..--.-......... ------- -...------ ------ ------ has been installed in accordance with the provisions of TITLE 5gof The State Environmental Code as described in the application for Disposal Works Construction Permit No. ----/--- ....... .. ............. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONS TISF CTORY. DATE.......... .......................... .--. .. ......................... ..--------------------- Inspector C�k r P � J U THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qq / TOWN OF BARNSTABLE ...............( FEE....)F.�O......... Dio-Venal Wo kii (9ja,n�g#/Jrudion unfit Permission is hereby granted------ � ------------------------•--•----------------•-•-•-•--•------......-----•---..._••...._.. to Construct ( VS or Re,air ( ) an, Individual F ewage Dis os yst -- ---•----------------•--•-----•------•----•-•--------•••---...•-•------••---............. Street q�, as shown on the application for Disposal Works Construction Perm o. -_���7_._ Dated.. ...................................... _.__ ---------•-•----•--•-•---•••••. Z. Board of Health DATE.....-`---�''�--T----`----i"'��-------�--•�� FORM 36508 HOBBS E WARREN,INC..PUBLISHERS 1l9 COMMONWEALTH OF MASSACHUSETTS u ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. fit Owner's Name. Owner's Address: 0 '000 R C VED Date of Inspection: Name of Inspector: (please rint),� _1 N1JED 7 ;'(�01 Company Name: Zrl,�`l` �/)2 '�iic� sa�eG��1C TOWN OF b:, Mailing Address: HEALTH pE;1r ' Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information rrported 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 . Needs.Further Evaluation by the Local Approving Authority. tls Inspector's Signature: Date: f� —�! j The system inspector shall submit a copy of this inspection report to theApproving 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 30,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future,under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 /I i Page 2 of.]i OFFICIAL INSPI';CTION;,FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORAM PART A CERTIFICATION (continued) Property Address: J .. Owner:.; `Date of Inspection: Inspection Sum:miry: Check A,B,C,D,.or E/ALWA S complete all of Section D A. ystem Passes: j I have not found:any information which indica'tes ih6t any of the failure criteria described in 310 CMR l5:303-or in 310`CMR 1:`34exist.'Anyfaiiure criteria-n,'revaluate'd`areindicated`below. i Comments: - I B. System Conditionally Passes: 7 One-or more system components as described in tL"Conditional.Pass"section need to be replaced or repaired. The system,upon completionof the replacement or repair, as approved by the Board of Health,Will pass. Answer yes,no or not determined(Y,N,ND),in the for the following statements. If"not determined"please explain. The.septic tank is metal and over 20 years old* or.-he 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.H..ealth. *A metal septic tank will pass inspectionif it:is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old.is availab}e. i 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 re,laced obstruction is removd distribution box is 1,,eled or.replaced ND explain: The system required pumping rriore than,'4-times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):.{ broken pipe(s)are replaced obstruction is removed i , l ND explain: . Page-3 of I'1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM.INSPECTION.FORM PART A CERTIFICATION(continued) Property Address:.0 Owner: Date of Inspection:. /9- p/ C. Further Evaluation is Required by the Board of Health: Conditions exist which,require further evaluation.b.y 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 CMR 15.303(1)(b).that the system is not functioning-in:a,:na:tner which.will protect public health,safety,and the environtent: 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 I 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 thm public health,safety and environment: _ The system has aseptic tank and soil absorption system(SAS)and the.SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within�a Zone 1 of a public water supply. The system has a septic tank and.SAS and the SAS is withim50 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: A 3 Page 4 of 1 1 OFFICIAL-INSPECTION FORM NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �,r4 f. a la Owner: Date.of Inspection:/e D. Systein Failure Criteria applicable to all systems: You must indicate"yes"or"no"to�each of the following for all inspections: Yes No _ 47 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ,:/Discharge or pond.ing 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 _ _A Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow :ERequired 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 watecsupply. _ J 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 cesspool or.privy is less than 100 feet but;greater than 50 feevfrom 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 J are triggered.A copy of the analysis must be attached to this form.] A0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 3I0 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.'systemahe 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a si:Qnificant threat, or answered "yes"in Section D above the,large system'has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system.in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 'Page 5 of 1.1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISYOSAL. SYSTEM!INSPECTION FORM PART B CHECKLIST Property Address: 391 Owner: 6 Date of Inspection: Check if the following have been done.You must.indicate"yes"or as to each of the.following: Yes No !1 _ Pumping.information.was provided by the owner, occupant, or-Board of Health. r//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 backup.? Was the site inspected for signs of break out? t" _ Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered,.opened, acid 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 fxom owner ).pro.vided with.information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soii Absorption System (SAS)on the site has.been determined based on: Yes no — Existing information.For example, a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C.is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)] 5 Page.6 of 1 l OFFICIAL-INSPECTION-FORM=NOT FOR VOLUNTARYASSESSM ENTS SUBSURFA. C:E SEWAGE DISPOSAL SYSTEM INSPI'JCTION FORM PART C - SYSTEM INFORMATION Property Address: � , Owner: Date of Inspection: / FLOW CONDITIONS RESIDENTIAL Number ofbedrooms(design)::. .: Number of.bedrooms (achaal):_. DESIGN flow based'on 310 CIv1R 15.203 (for example: 11:0 gpd x#of bedrooms): Number of current residents: Does residence.'have.a garbage grinder(yes or no):.A0 Is laundry on a separate sewage`system (yes or no): Tif„yes separate inspection required] Laundry system inspected (yes or no):,-nv Seasonal use: (yes or no) Water meter readings, if alClable '(last 2 years usage(gPd)): Sump pump(yes or no):n© Last date of occupancy:;Com :w/o�oo j COMMERCIAL/INDUSTRIAL.0.0 Type of establishment:.. Design flou,(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):' Wafer meter readings, if available: Last date of occupancy/user OTHER(describe): GENERAL INFORMATION Pumping Records Source•of information:. nAQ 19 9 Was system pumped as part of the inspection.(y s or no): /10 If es volume pumped: `yes, P P gallons--Bow was quantity pumped determined? Reason Tor.pumping; . TYPE OF SYSIrEM r,/'Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _:Privy —Shared System.(yes or no)(if yes, attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be . obtained from system owner) -Tight tank _Attach a copy'of the DEP.approval —Other'(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): (? Page 7 of l l` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -14 ,"el 1 Owner: a Date of Inspection: BUILDING SEWER(locate on site plan) mod. Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: r/ (locate on site plan) Depth below grade: Material of construction: b-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,,rj' X 4 � S . Sludge depth: 07.,., y. 4� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ./ Distance from top of scum to top of outlet tee or baffle: 2- / Distance from bottom of scum to bottom of outlet tee or baffle: /® How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as re ated to outlet invert, evidenc of leakage,etc.): : 01 GREASE TRAPY0:Aiocate.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 71 OFFICIAL INSPECTIONFORM—NOT:FOR VOLUNTARY"ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM } PART C SYSTEM INFORMATION(continued) Property Address: Owner:. Date of Inspection:2/a9 1,, TIGHT or HOLDING TANK: A)Q '(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarmpresent(yes or no): Alarm level: Alarm in working order(yes or no): Date of fast- pumping-Comments (condition of alarm and float.switches, etc.): DISTRIBUTION BOX: l (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:` la ey Comments(note if box is level and distributionlets equal, an evidence of solids carryover,an evidence.of q Y �' Y lea «e into or out of box, .q PUMP CHAMBER:Aft)(locate on'sit`e 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 T 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) • 1 Property Address: Owner: pad Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): �(locate.on site pla.n.,excavation not required). .If SAS not located explain why: Type r/ leaching.pits;number: / leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, etc.)• 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-or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,:condition of vegetation,etc.): PRIVY: PCO(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 I i Page 10 of I l OFFICIAL INSPECTION-FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6V f. Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includi�]Ig ties to at-least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. i } Ql k a n i j . I10 Page I I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION (continued) Property Address: 9 Owner: Date of Inspection: SITE.EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water J 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 -Iealth-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established-the high ground water elevation CC/7 11 �I xs Permit Number: Date: 4 Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: /� J� .4111, Lot No. A; Owner: j% �1 J "11f1 Address: Contractor: �T ✓� f} Address: Notes: /�t�G�lr✓ '//1J�' 1�15 STEP 1 Measure depth to water table a � ? � to nearest 1/10 ft. ...................:...........:.............................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: O APPropriate index well.......................................... 'Dw253 © Water-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 water by subtracting the water- level adjustment (STEP 4) _ from measured depth to water Z levelat site (STEP 1) ............................................................................................................. ' Figure 13.—Reproducible computation form. i II 743 t ! -41 j11l iJ t�t I'^-. �_ 1 } 'r ;; i •__'-_�- L-�_r._i I ( r -. , - ' _ 1 ! •j _ ,-- _ 1. r i T_ 'F I1. - _ - 1- �-- F__._ :�L-. _'.. ._i 1 1 ? ,_. 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