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HomeMy WebLinkAboutInspection Report 2014 Oct 05 - Front � Commonwealth of Massachusetts , Title 5 Official Inspection Form '"` ° '� '�:`��� Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A ��2�N'i� , /� PropertyAddwss ` ..� �3� r�. HUGHESJOANN � 6 � r� Or,mer Owner's Name .� , -�� . . informationis YarmoutllpoR MA 02675 10/05/�4 required for every pa9e. City/Town Stete Zlp Code Dete ot I�pection Inspection results must be submitted on this form. Inspection forms may rat be altered in any way.Please see completeness checklist at the end of Uie form. ImpoRaM:When A. General information fiili�g ou[Porms on the canputer, use ony nre ac � �nspector: key to move your cursor-do rwt Trevor Kellett use the retum Name of Irepector key. � TKSepticlnspections d CompanyName 38 Vacation Lane Company Atltlress �. West Yarmouth MA 02673 cnyirow� s�ca zp coda 508-579-5502 S113744 Talepho`re Number Licensa Number B. Certification I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of Me time of the inspection. The inspection was performed based on my training and experience in the proper functlon and maintenance of on site sew�qe disposai systems. I am a DEP approved system inspector pursuaM to Section 15.340 of Title 5(310 CMR 15.000�.The system: � Passes ❑ Cond'Rionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approvirg Authority � �-�ee�� �a�s��a ms,�tor:s�9�aare �ata The system inspector shall submd a copy of this inspection repoR to the Approving Authority(Board of Heatth or DEP)within 30 days of completirg this i�spection. 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 submd the report to the appropriate regional office of the DEP. The original should be serrt to the system owner and copies sent to the buyer, if appiicable, and the approving authority. •"`This report oMy describes conditions at the time of inspection and under the condfions d use at that time.This inspectian dces not address how tl�e system will pertorm in the future under the same or diiferent conditions of use. is�•ana t�ue s onaai m�mm vam:smanac�sawwe a�sysex�•a�ee�m n � ��� � 1 � Commonwealth of Massachusetts Title 5 Official Inspection Form SubsuAace Sewage Disposal Systern Fwm-Not for Voluntary Assessments 56 Route 6A Roperly Address HUGHESJOANN �e� Owner's Name �reyui.ed�wrevery YarmoufhpoR MA 02675 10/05/14 pe9e. Cily/Town Sfate Zip Code Daffi of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E l always complete all of Section D A) System Passes: � I have not found any i�formation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR �5.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionalty Passes: ❑ One or more system components as tlescribed 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) �strudurally uruound, exhibfts substantial infittration or exfittration or tank failure is imminent. System will pass inspection 'rf the existing tank is repiaced with a complyirg septic tank as approved by the Board of Heatth. "A metai septic tank will pass inspection if it is structurally sound, not leaking arM if a Certficate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): itins.3�13 TYEe 501Atlal MSPec4an Fam:SLEsniece Sewa9e OisP���s1e�•Pepe 2 0117 � Commonweaith of Massachusetts , Title 5 Official Inspection Form Subsurtace Sewage Disposal Sysb�n Form-Not for Voluntary AssessmeMs 56 Route 6A Property Address HUGHESJOANN Ormer pmmer's Name ��Of"abO�5 Yarmouthport MA 02675 '10/OSl14 required for every �9a �gyRo� State Zip Code Data of Im,pection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operafional. System will pass with Board of Heatth approval if pumpsialarms are repaired. B) System Condkionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to lxoken or obstructed pipe(s)or due to a broken,settled or uneven disVibution box. System wili pass inspection if(with approval of Board of Heafth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(F�cplain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(F�cplain beiow): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(F�cplain 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) Furfher Evaluation is Required by the Board of Health: ❑ Conddions exist which require further evaluation by the Board of Heatth in order to determine if the system is failing to protect public heatth, safety or the environmeM. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)�b)that Uie syst�n is not functioning in a manner which will protect public health, safety and the environmeM: ❑ Cesspool or privy is wRhin 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins.Yt3 TRe S Ofitld InsP�m Fam 9iGsvface iexege UsP�tl S)5fen'Pa9e 3 d 17 i/_ [ � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A Property Addreu HUGHESJOANN �ef O.mer's Nama im�ormatlon is ry Yarmouth R uireeforeve FN� MA 02675 10lOS/14 pa9e. Cdy/Town Sfate Zip Code �te of Irspectbn B. Certification (cont.) 2. System will fail unless the Baard of Health(and Public Water Suppli�, 'rf any) determines that U�e system is functioning in a manner that protects Me 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 surtace water supply or tributary to a surtace 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 welM'. Method used to determine distance: "'This system passes if the well water analysis, pertormed at a DEP certified Iaboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nihogen 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) Systa�n 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 componerrt due to overloaded or clogged SAS or cesspool � � Discharge or ponding of effluent to the surtace of the ground or surtace 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 c�spool � � Liquid depth in cesspool is less than 6' below invert or available volume is less than 'f dayflow tSMs-3�13 TNe 5 OlRdal In �tttlan Fam:SiDvrfem Ssda9e L1sG�bY�•P�4 U 1] � Commonwealth of Massachusetts Titie 5 Official Inspection Form Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A a�o�m naa.�ss HUGHESJOANN �^a� Ovrt�er's Name informanonis Yarmouthport MA 02675 10/05/�4 required for every �ge �yRo� Smte Zip Code Date of Inspection B. Certification (cont.) Yes No � � Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ � Any podion 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 surtace water supply. ❑ � Any portion of a cesspool or privy is within a 2one 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 lwt greater than 50 feet from a pnvate water supply well with no acceptable water quali[y analysis. [fhis sysbem passes if the well water analysis,pertormed at a DEP certified laboratwy,for fecal colffwm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to w less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be atfached to this form.] � � The system is a cesspool serving a facildy with a design flow of 2000gpd- 'I O,OOOgpd. � � The system fails. I have determined that one or more of the above failure crderia exist as described in 3�0 CMR 15.303,therefore the system fails.The system owner should contad the Board of Health to determine what wiii 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 followirg, in addition to the questiorrs in Section D. Yes No ❑ ❑ the system is within 4�feet of a surtace drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surtace drinking water supply � � the system is tocated in a nitrogen sensitive area(Interim Wellhead Protection P,rea—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 corsidered a sgnificant threat, or answered°yes° in Section D above the large system has failed. The owner or operator of any iarge system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance wRh 310 CMR 15.304. 7he system owner should contact the appropriate regional office of the Department t5ins•3H3 Title 5 OlAtlel Buperdm Farm SLDsalece Srxega Gsposel Sysbn•Pege 5 M 1T � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtace Sewage Disposal Systern Form-Not for Voluntary Assessments 56 Route 6A PropeM1y Adtlress HUGHESJOANN �� Owner's Nama �rdormetion is yarmouth rt required ror e�ery f� MA 02675 10/05/14 psye. �Y�Ta`� State Zip Code Date of Irapecdon 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, occuparrt, or Board of Health ❑ � Were any of the system components pumped out in the previous iwo weeks? � ❑ Has the system received normal flovus in the previous iwo week period? � � Have large volumes of water been introduced to the system recently or as part of this inspection? � � Were as buift 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 si[e inspected for signs of break out? � ❑ Were all system components, excludirx�the SAS, located on sde7 � ❑ 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(arxl occupants rf different from owner)provided with information on the proper maintenance of subsurtace sewage disposal systems? The size and location of the Soil•Absorption System(SAS�on the sde has been determined based on: � ❑ 6cisting information. For example, a plan at the Board of Heatth. � � Determined in the field(if any of the failure crderia related to Part C is at issue approximation of distance is unacceptable)[3�0 CMR 15.302(5)j D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow b�ed on 310 CMR 15.203(for example: 1�0 gpd x#of bedrooms): 440 �rs•3�13 TMe 501�tla1 InspeUm Fam_S�Dsxfe¢Sewege qsppyxl yyytem.ppe 6 d 1] � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Nat for Voluntary AssessmeMs 56 Route 6A Proparty Address HUGHESJOANN �^a� Wmer's Name intomaeon is yarmouthport MA 02675 10/OS/l4 required for every wga Cily/Torm State Zip Code Date M Inspectbn D. System Information Oescription: 1 Number of current residents. Dces residence have a garb�qe grinder? ❑ Yes � No Is laundry on a separate sewage system?(Include laundry system inspection � Yes � No information in this report) Laundry system inspected? ❑ Yes � No Seasonal use? ❑ Yes � No Water meter readings, rf available(last 2 years usage(gpd)): � Detail: ��'`3 l46 CJ '-�C� � ,IC�� �-IS ��o Sump pump? ❑ Yes � No Last date of occu nc : current Pa Y pace CommerciaUlndustrial Flow Conditions: Type of Establishment: Desgn flow(based on 310 CMR�5.203): �ibns perday�gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap preseM? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sandary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ns•3113 Tke 5 011ldal InsG�on Form:SW euface Sewe9e qW�SY�^'Pa9a T M 1] � Commonwealth of Massachusetts Title 5 Official inspection Form Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A Property Adtlress HUGHESJOANN �� Ovmer's Name �,`��y°��d;�a,re,y Yarmouihport MA 02675 10/O5/14 page. Cily/Tovm SWte Zip Code Date of Inspection D. System Information �cont.) Last date of xcupancy/use: oa�e Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes � No If yes, volume pumped: gelbns How was quantity pumped determined? Reason for pumping: Type of System: � Septic tank, disfribution box, soil absorption system ❑ Single cesspool ❑ Overflowcesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ InnovativelARernative technology. Attach a copy of the currerrt 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 coMract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): �5ins.3/13 TiAe 5 OIRtlBI M.syemm Fortn:SLb9alece Se�'+9e Oisposel Sysbm.payg 8 of i7 � Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A Property Address HUGHESJOANN Ov-mer p,oner's Name iMormaeonis yarmouthport MA 02675 10/OSl14 required for avery pa9e. CitylTown State Zip CMa Date ot Inspectbn D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 17N 1/96 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth belowgrade: �'� Material of construction: ❑cast iron �40 PVC ❑ other(explain): Distance from private water supply well or suction line: fe�t Comments(on co�dition ofjoints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 9 feat Material of construction: � concrete ❑ metal ❑fibergiass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirtned by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000g Dimensions: 6" Sludge depth: !Sins•3I13 TKa 501itlel Nspa9m Fatrc SLDarface Sey'aga OiaP�SY�^•P�9 aL 1] � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtace Sewage Disposal Sysbem Form-Not for Voluntary Assessments 56 Route 6A Property Address HUGHESJOANN a^'^a� OomersName ey,,;��;e1e YarmouthpoR MA 02675 10/05/14 ry page. Cily/Tovm SWte Zip Code Date of Impection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baftle � Scum thickness � Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 19 How were dimensions determined? measured Comments(on pumpng recommendations, inlet and outlet tee or baffle condftion, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is structurally sound and water tight with liquid at the outlet invert, both tees are intact and tank dces not need to be pumped Grease Trap(locate on site plan): Depth below grade: feat Material of construction: ❑concrete ❑ metal ❑fibergiass ❑polyethylene ❑other(explain): Dimeruions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of ou[let tee or baffle Date of last pumping: Data i5i�•Y13 Title 5 OTItla1 b�sPedm Fortn'�vrtfece Sawege USPosd Sf��•Po9e 10 U 1] � Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurtace Sewage Disp�al System Form-Not for Voluntary AssessmeMs 56 Route 6A Proparty Addreu HUGHESJOANN b+mer W.neYs Name "�O`�`�eOO� Yarmouth rt MA 02675 '10{05/14 required forevery PD page. CilyRov`n State Zip Cotle Data of I�paction D. System Information �cont.� Comments(on pumpir�q recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid leve�as related to outlet invert, evidence of leakage, etc.): Tight or Holding Ta�k(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: galbre Design Flow y�ibns�r a�y Alarm present: ❑ Yes ❑ No Ala�m level: Alartn in worldng order ❑ Yes ❑ No Date of last pumpirx�: ��a Comments(condition of alarm and float switches, etc.): 'Attach copy of curreM pumping coMract(required). Is copy attached? ❑ Yes ❑ No 15Ins•3/13 Tltle 5 OIReN Napecqm Foim:S�Ewrtam Sewage Oiayosal System•Pege 11 d t] � Commonwealth of Massachusetts � � Title 5 Official Inspection Form ' Subsudace Sewage Disposal System Form-Not for Voluntary AssessmeMs 56 Route 6A PropeRy Addtess HUGHESJOANN _ �e� Ov.neYs Name i�ormeoon is Yarmouthport MA 02675 '10/05/14 required/or every Pa9e. CiIYlTown Sfate ZiP Code Date of Irepecdon D. System Information (cont.) Dishibution Box('rf present must be opened)(locate on si[e plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is level and water tight wi[h no sig�of carry over Pump Chamber(locate on sde pian): Pumps in working order: � Yes ❑ No' Alarms in working order: � Yes ❑ No' Comments(note cond'Rion of pump chamber, condi[ion of pumps and appurtenances, etc.): not a chamber just a pump assisting the water from the pool house to the tank `If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, eucavation not required): If SAS not located, expiain why: 15irrs.Yt3 TAe 501Rtlel Insyectim Fortn:SAwrteco Sewnge qspoal Syalem'P�a 12 0l t] � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A Properly Address HUGHESJOANN �^a� Ommer's Name ,ay�,��ra„a,y Yarmouthport MA 02675 10/05/14 paga. Cily/Town State Zip Code Date of Irepaction D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: � leaching trenches number, length: 3 ❑ teaching fields number, dimensiors: ❑ overflowcesspool number: ❑ innovative/atternative system Type/name of technology: Comments(note conddion of soil,signs of hydraulic hailure, level of ponding, damp soil, condition of vegetation, etc.): SAS consists of 3 trenches that are 2'by 25'there is no ponding or hiqh stainin in the stones Cesspools(cesspool must be pumped as part of inspection)(locate on sde plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dime�ions of cesspool Materials of corrstruction Indication of groundwater inflow ❑ Yes ❑ No t5ins.Y13 TRa 501fltld MapaNm Form:Silwrtem$awe9a pi�mol System•Wqa 13 af tl � Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A �.o�m naare:s HUGHESJOANN �� Ovmer's Name infom�ationis YarmouthpoR MA 02675 10105/�4 required Mr every �9e. Cily/7ovm State Zip Code Date of Inspection D. System Information �cont.) Comments(note cond'Rion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(iocate on site plan): Materials of construction: Dimensions — Depth of solids - Comments(note conddion of soil, signs of hydraulic failure, level of ponding, condi�on of vegetation, etc.): �y.y�3 Title 501idel Inspe3m Fam:StAwrtaca Sewqqe Oispo�Sy51em'Ppe 11 M 1T � Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurtace Sewage Disposal Syst�n Form-Not for Voluntary Assessmerrts 56 Route 6A Properry Address HUGHESJOANN �`"T'a� Ownar's Name inf�ormation Is ry Yarmouth re uiredforeve f�rt MA 02675 �0/05/14 Pa9e. Cily/Toxn State Zip Co� Date of Irepactio� D. System Information �cont.) Sketch Of Sewage Disposal System: Provide a view of the sew�qe disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pubiic water supply enters the building. Check one of the boxes below � handsketch in the area below ❑ drewing attached separately From"Pool House° C (H(k lN kl"DJ SE — �(1.ph1 i A g 4 3 1 61)47 62)78 C1)39 C2�4 C3)27 C4)31 A3)33 2 A4)39 Inspection Hole t5in5•3/13 � ritle 501Atia1 Napa3m Form SLpyrfare Se�.pge Oiyc�l y)yg�.pg9e 15 0(1l ;� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sew�e Disposal Syst�Form-Not for Voluntary AssessmeMs 56 Route 6A Property Adaress HUGHESJOANN Oartier pwner's Name iMommeon is yarmoUthport MA 02675 10/05/14 required for every �9a �,Re,,M State Zip Code Date of Inspectlon D. System Information (cont.) Site Exam: � Check Slope ❑ Surface water � Check cellar ❑ Shallow v✓ells 20+ Estimated depth to high ground water. f�i Please indicate all methods used to determine the high ground water elevatio�: ❑ Obtained from system desgn plans on record If checked,date of design plan reviewed: oace ❑ Observed site(abutting propertylobservation hole within 150 feet of SAS) ❑ Checked with local Board of Heatth-explain: ❑ Checked with local excavators, installers-(attach documentation) � Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Ma show GW at over 20 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. TMa 5 Oif�atl InsperEm Form:Sdsvfe�e ScwN°asP^��°�^•P°9°16 d 1] t5irrs•3�13 � Commonwealth of Massachusetts , Title 5 Officiai Inspection Form � Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments 56 Route 6A Properly Addreu HUGHESJOANN �^a� OwnersName iniqormation is ry Yarmoutli re uiredforave Po� MA 02675 �0/OSl�4 Pa9e. Ciry/Tovm State Zip Code Oata of I's pectbn E. Report Completeness Checklist � Inspection Summary: A, B, C, D, or E checked � Inspection Summary D(System Failure Criteria Applicable to AII Systems)completed � System Information—Estimated depth to hgh groundwater � Sketch of Sew,�qe Disposal System either drawn on page�5 or attached in separate file t51ns•3113 rme a rneav ms�cem ro�m:sunwnaca sr.�pe w�ow sY�em•pa�n a i,