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Commonwealth of Massachusetts
Title 5 Official In '
Subsurface Sewage Disposal stem Form Not for
56 Route 6A (system in b9ck) (REVISED
Property Address
HUGHES JOANN
Owner's Name
Cityfrown
Inspection results
way. Please see c4
A. General Information
Inspector:
Trevor Kellett
Name of Inspector
TK Septic Inspections
Company Name
38 Vacation Lane
Company Address
West Yarmouth
CitytTown
508-579-5502
Telephone Number
B. Certification
Form,1-1
°.'tE fD E._. t��
_ I I- T
ntary Assessments
MA02675
Stat Zip Code
10/22/14
Date of Inspection
-this form. Inspection forms may not be altered in any
at the enl
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/16/14
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
nns • 3113 Tile 5 Olfidal Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
re -,-e j'
tt at Ity
Ie
� Commonwealth of Massachusetts �
Title 5 Official Inspection Form
Subsurtace Sewage Disposal Systern Form-Not for Voluntary Assessments
56 Route 6A (system in back)(REVISED)
Property Address
HUGHESJOANN
�a� Orvner's Name
irAormaiion a
requiredforevery YafmoUtlipprt MA 02675 10/22t14
Pa9e. CRy/Town Sate Zip Code Date of Irepection
B. Certification (cont.)
Irupection Summary: Check qB,C,D or E 1 always complete all of Section D
A} Systetn Passes:
� I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 3'10 CMR 15.304 exist. Any failure criteria not evaluated are
irWicated below.
Comments:
B) System Conditionalty passes:
❑ One or more system componenis as described in the'Conditional Pass'section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for°yes', 'no'or'not determined'(Y, N, ND)for the following statemerris. If'rwt
determined,° please eacplain.
The septic tank is metal and over 20 years old'or the septic fank(whether metal or not)is structurally
unsound, exhibits substantial infiRration or exflltration or tank failure�imminent System witl pass
inspection 'rf the exis6ng tank is repiaced with a complying septic tank as approved by the Board of
HeaRh.
`A metal septic tank will pass inspection if it is structurally sound, not leaking and rf a Certificate of
Compiiance indicatirg that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
,
13bn•3It3
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� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Systern Form-Not for Voluntary Assessments
56 Route 6A (system in back)(REVISED)
aro�rtr nddress
HUGHESJOANN
�� OvmeYs Name
��eeOOb ,y Yarmouth
uired for ave Port MA 02675 1 W22/�4
pa9e. Cily/Tox� Slate Zip Code Date of Irrspect'an
B. Certification (conc.�
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(corrt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken w obstruded pipe(s)or due to a broken,settled or uneven d�tribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distributlon 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 'rf(with approval of the Board of Heatth):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below�:
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Ev�uation is Req�ared by the Board of H�Itlr
❑ Cond'Rions eacist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public heatth,safety or the environmeM.
7. System will pass unless Board of Healtli determines in accordance with 310 CMR
15.303(7)(b)that the system is not functioning in a manner which will protect puaic h�tth,
safety ar�d the environmeM:
❑ Cesspool or privy is vvithin 50 feet of a surtace water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a satt marsh
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� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal Syst�n Form-Not for Voluntary AssessmeMs
56 Route 6A (system in back)(REVISED)
propeKy ndaress
HUGHESJOANN
owner orner•s Name
iMormetion is YarmoUthport MA 02675 10/22/14
required for every
Pa9a- �YlTown SIaM Zip Code Date of Irspeation
B. Certification (cont.)
2. System will fail uMess tl�e Board of Health(and Public Waber Supplier,if any)
determines that tlie system is functioning in a manner that protects tlie public he�lifi,
safety�d e�vironment:
❑ The system has a septic tank and soii absorption system(SAS)and the SAS is within
10�feet of a surtace water supply or tributary to a surface water suppiy.
❑ The system has a se�ic tank and SAS and the SAS is withi�a Zone 1 of a public water
supply.
❑ The system has a septic tank arW 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 welt".
Method used to determine distance:
"This system passes 'rf the well water analysis, pertormed at a DEP certified laboratory, for fecal
col'rform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
io 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) Sysbein Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspectiw�s:
Yes No
� � Backup of sewage into facility or system component due to overloaded w
dogged SAS or cesspool
� � Discharge or ponding of eifluerd to the surface of the ground or surtace waters
due to an overloaded or cic�gged 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 inveR or available volume is less
than 14 day flow
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;� Commonwealth of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disposal Syst�n Form-Not for VoluMary AssessmeMs
56 Route 6A (system in back)(REVISED)
Froparty nddreu
HUGHESJOANN
�r O.xieYs Name
iMomwtion"s ry YafrtloUV1 rt
raqured for eva Po MA 02675 10/22/14
page. CdylTca*� Sate Zip Code Date of Inspactlon
B. Certification (cont.)
Yes No
� � Required pumping more than 4 times in the I�t year NOT due to clogged or
obstructed pipe(s). Number of times pumped:_
❑ � My portion of the SAS,cesspool or privy is below hgh ground water elevation.
� � My portion of cesspooi or prnry is within 100 feet of a surFace water suppiy or
tributary to a surtace water supply.
❑ � �Y p��on of a cesspooi or privy is within a Zone 1 of a puWic well.
❑ � My poAion of a cesspool or privy is within 50 feet of a private water suppiy well.
❑ � Any portion of a cesspool or prnry is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analys�. [f his
sysbem passes'rf the well water analysis,performed at a DEP certified
laboratory,fw fecal coliForm bacteria indicates absent and the presence
of ammonia niVogen and nitrate nitrogen is equal to or less ttian 5 ppm,
provided tliat no other failure criteria are triggered.A copy d the analysis
and diain�q�stody must be attached to tlus form.]
� � The system is a cesspool serving a facility with a design flow of 2000gpd-
10,OOOgpd.
� � The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the tailure.
E) Large Syslems: To be considered a large system the systern must serve a facility with a
design flow of 10.000 gpd to 15,000 gpd.
For large systems,you must indicate either`yes' or°no°to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surFace dnnking water supply
❑ ❑ the system is located in a nitrogen sensdive area(IMerim Wellhead Protection
Area—NVPA)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 sgnificant threat,
or answered°yes° in Section D above the large system has failed. The owner or operator of any large
system considered a signficaM threat under Section E or failed under Section D shall upgrade the
system in accorclance with 310 CMR 15.304. The system owner should contad the appropriate
regional office of the Departmerrt
�•ana rroe e arb.�
„��W�m'94m+bce Sb�ge Oi�osel S)5Mn'Pa�geS a(1]
� Commornvealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disp�al Systern Form -Not for Voluntary AssessmeMs
56 Route 6A (system in badc)(REVISED)
property nddress
HUGHESJOANN
�e� Umers Nama
iMomretiona Yarmoutliport MA 02675 10/'1?l�4
required for every
�9e. �,Ro� State =iP Code Date of Irepeo6on
C. Checklist
Check rf the following have been done. You must indicate'yes'or'no' as to each of the following:
Yes No
❑ � Pumping information v✓as provided by the owner, occupant, or Board of Health
❑ � Were any of the system componerits pumped out in the previous lwo 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 irspection?
� � Were as buitt plans of the system obtained and examined?(If they were not
available note as WA)
� ❑ Was the facility or dwelling inspected for signs of sewage back up?
� ❑ Was ttie site inspected for signs of break ouY?
� ❑ Were ail system components,excluding the SAS, located on site?
� ❑ Were the septic tank manhol�uncovered, opened, and the interior of the tank
irspected for the cordRion of the baffles or tees, material of construdion,
dimensions, depth of liquid,depth of sludge and depth of scum?
� � Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurtace sewage disposal systems?
The size a�d location of the Soil Abswption System(SAS)on the site has
been determined based on:
� ❑ Existing information. For example, a pian atthe Board of Heatth.
� � 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(5)]
D. System information
Residentlat Flow Conditions:
Number of bedrooms(desgn): 4 Number of bedrooms(actuaq:
4
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): ��
M.�ins•3/13 TNe 5 Ofitlel Nyeclm Fam:SDaahce Sewege Di�sel Sfl�^'P�6 ot 1T
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for VoluMary Assessments
56 Route 6A (system in back)(REVISED)
Proaertv Adaress
HUGHESJOANN
�� OwneYs Name
���eon`� Yarmouthport MA 02675 10/22/14
requead for every
pe9e. CitY�To�"*� State Zip Code Date oi IrspacUon
D. System Information
Descnption:
Number of current residents: �
Does residence have a garb�qe grinder? ❑ Yes � No
Is laundry on a separate sew�e system?(Include laundry system inspection Yes � No
infortnation in this report.) �
l.aundry system inspected? ❑ Yes � No
Se�onal use? ❑ Yes � No
Water meter readings, 'rf available(last 2 years us�qe(gpd)):
Detail:
Sump pump? ❑ Yes � No
Last date of occupancy: current
��
Commercial/lndustrial Flow Conditioru:
Type of Establishment:
Design flow(based on 3�0 CMR 15203): �ib�s�er aay��a�
Basis of design flow(seats/personslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industnal waste holding tank preseM? ❑ Yes ❑ No
Nonsanitary waste discharged to the Tdle 5 system? ❑ Yes ❑ No
Water meter readings, 'rf avaiiable:
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t��acYon Fam:9�ae4ro 9a�¢dryosg S�Sy�ri'Ppa'!af 1]
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal Systern Form-Not for Voluntary Assessmerrts
56 Route 6A (system in badc)(REVISED)
propeAy adareu
HUGHESJOANN
��e� Owner's Name
irrformetion's YarmoUihport MA 02675 �O/'12l14
98ired for every cayrtow� s��e zrc+coda oa�e or i��a;on
D. System Information (cont.)
Lastdate of occupancyluse: �
Otl�er(describe below):
General Information
Pumping Recwds:
Source of information:
Was system pumped as part ofthe inspection? ❑ Yes ❑ No
If yes,volume pumped: �wo�
How was quantity pumped determined?
Reason for pumping:
Type of Systern:
❑ Septic tank,distribution box,soil absorption system
� Single cesspool
❑ oYertroW�sPooi
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ lnnovative/Attemative technology.Attach a copy of the curreM operation and
mairdenance coMrect(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under corrtract
❑ TigM tank. Attach a copy of the DEP approval.
� Other(describe):
t51ns.3/13 Ttle 5 Olfidtl h�u.Y^n Fmn:9NsuYx S�we9e Q�P^��^'PWe 8 af l]
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal Sys�n Form-Not for Volurrtary AssessmeMs
56 Route 6A (system in badc)(REVISED)
Property Address
HUGHESJOANN
�� Owrar's Name
r w ed�o,e„e Yarmouthport MA 02675 10122/14
ry
page. Cily�Town Sate Zip Code Date of Irspection
D. System Informatlon (corrt.�
Approximate age of all components,date installed(rf known)and source of infwmation:
40 years+
Were sewge odors detected when arrivir�at the site? ❑ Yes ❑ No
Building Sewer{Ixate on site plan):
Depth belowgrade: 2'S
faet
Material of construction:
�cast iron ❑40 PVC ❑ other(eacplain):
Distance from private vrater supply well or suction line: ree�
Comments(on conddion ofjoirrts,verrting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: ree�
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
tf tank is metal, list age:
y�rs
Is age confirmed by a Certificate of Compliance9(attach a copy of certificate) ❑ Yes ❑ No
Dimersions:
Sludge depth:
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� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments
56 Route 6A (system in badc)(REVISED)
proparty ndareu
HUGHESJOANN
oa+�. o�rs Neme
inrommeon a yarmou�port MA 02675 'IO/22/14
requiretl for every
�9e. �y�7ap� Sate Zip Code Date of Irspeotio�
D. System information �cont.)
Septic Tardc(cont.)
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 baffie
Distance from bottom of scum to bottom of outlet tee or baffle
How were dime�sions detertnined?
Comments(on pumpirg recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leak�e, etc.):
Grease Trap(locate on sde plan):
Depth below grade: ��
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance f�om 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: �e
t5krs.Y13 Ti�e 501Rdal I�ection Fwm:SWeebceS�wege Ospaaal Syelam'Pege 10 0(17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disp�al System Form-Not for Volurrtary Assessments
56 Route 6A (system in back)(REVISED)
Proaeev nddress
HUGHESJOANN
�� OMne�'s Name
eyina4on R ,y Yarmouth
uiredforeve Port MA 02675 �0/22/�4
Pa9e. CitYliown State Zip Code Data of Irepection
D. System Information (cont.�
Comments(on pumpng recommendations, inlet and outlet tee or baflle conddion, structural integrity,
liquid levels as related to outlet invert, evidence of leak�e, etc.):
Tight or Holding Tank(tank mist be pumped at time of inspection)(locate on site plan):
Depth bebw grade:
Ma[erial of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gauons
Design Flow
�Ib�s per day
Alarm Exxesent: ❑ Yes ❑ No
Alartn level: PJartn in working order ❑ Yes ❑ No
Date of I�t pumping: o�e
CommeMs(condition of alartn and float switches, etc.):
'Attach copy of curterrt pumping contract(required). Is copy attached? ❑ Yes ❑ No
�•ana nea s anaa v�s�Fo�:s�n�,rt�,s,.�o�+sy�•wm,i i m i�
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for VoluMary AssessmerAs
56 Route 6A (system in badc)(REVISED)
property Aadress
HUGHESJOANN
O+mer Owner's Name
iMormetion's Yarmoutliport MA 02675 10/22/l4
required for every
W9a. Ciyl/Torn Slate Zip Code Date ot I�pection
D. System Information (cont.)
Distribution Boz('rf present must be opened)(locate on sde plan):
Depth of liquid level above outlet irnert N!A
Commerrts(note'rf box is level and distribution to outlets equal, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
No D BOX
Pump Chamber(locate on sde plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in v�wking order: ❑ Yes ❑ No'
Commerris(note cond'Rion of pump chamber, condftion of pumps and appurte�ances, etc.):
'If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorptia�System(SAS)(locate on site plan, excavation not required):
If SAS not located,explai�why:
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� Commonwealth of Massachusetts
� Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary AssessmeMs
56 Route 6A (system in badc)(REVISED)
ProPertY Atltlreu
HUGHESJOANN
�� Owner's Narre
re"`p6on� ,y Yarmouth rt
quired for eve W MA 02675 10122/14
Pa9e. Cil}'�Tov�n SWte Zip Code Date of Irapedion
D. System Information (coM.�
Type:
❑ leachi�g pits number:
❑ leaching chambers number:
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overtlow cesspool number.
❑ innovativelatternative system
Type/name of technology:
CommeMs(note conddion of soil, signs of hydraulic failure, level of pondirg,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 �
Deptti of solids layer �
Depth of scum layer �
Dimensions of cesspool Sk5'
Materials of corstrudion drywell block
Indication of groundwater intlow ❑ Yes � No
a.�s-ana rn.a ama i
^�ac9m Fmn:SLEavhcaSeweye Olspmel Sryiwn'Pega 13 of 17
� Commornveald� of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form-Not for VoluMary AssessmeMs
56 Route 6A (system in badc)(REVISED)
aroPerty nddreu
HUGHESJOANN
OMner pyner's Name
inwrmetwn is YaRnouthport MA 02675 1022/l4
required for every
Pa9a. CilylTovn State Zip Code Date of Itspeclion
D. System Information (cont.)
CommeMs(note condition of soil, sigrs of hydraulic failure, level of pondirg, condRion of vegetation,
etc.):
The 5x7 drywell block pif only seems to service a sink in the kdchen there is an 8 inch stain above the
water level in the pit this system only services one of the kitchen sinks
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Commerds(note condition of soil, signs of hydraulic failure, level of pondirlq, conddion of vegetation,
etc.):
x,x�a.an3 TiM 501Pdel lnspec9o^Fam:5u0a�ce Se.rape�pasel bY�'P6a 1/af 17
� Commonwealth of Massachusetts
Titie 5 Official Inspection Form
Subsurface Sewage Disposal Syst�n Form-Not for Voluntary AssessmeMs
56 Route 6A (system in back)(REVISED)
Property Address
HUGHESJOANN
�� Owner's Nama
�,Bq"re��R ,y Yarmouth
uired ior eve Port MA 02675 10/22/14
Pa9e. CitY/Tox� Sate Zip Code Date of Inspection
D. System Information (corn.)
Sketch Of Sew�ge Disp�al System: Provide a view of the sewage disp�al system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wel�within 100 feet Lxate
where public water supply enters the twilding. Check one of the boxes below
� handsketch in the area below
❑ drawing attached separatety
PoolHouse
13.5 6
Back of house
�
�s-ana ree s omor i
. nspe�2m Fmn:sueaamrs Ss+'eoa G�+System•Pege�5 m n
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal Syst�n Form-Not for Voluntary Assessmerds
56 Route 6A (system in badc) (REVISED)
properry nddress
HUGHESJOANN
�e� Owner's Name
i�ormaeon is Yafmoulhport MA 02675 10/'L2/14
required for every
Pa9e. �YlToan State ZiP Code Date of Irspe�tion
D. System Information (corn.)
s�ro��:
� Check Slope
❑ Surtace water
� Check cel�ar
❑ Shallowwells
20+
Estimated de�h to high ground water: �e�
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design pians on record
If checked,date of design plan revievved: ��
❑ Observed site(abuttirg property/observation hole wdhin '150 feet of SAS)
❑ Checked with local Board of Heatth-explain:
❑ Checked with local excavators, installers-(attach documentation)
� Accessed USGS database-eacplain:
You must describe how you established the high ground water elevation:
USGS Maps show GW at over 20 feet
Befwe flling this Inspection Report, please see Report Completeness Checklist on ne�ct page•
�ns.ana rna s orcwd i��:suo�a�s�me a��"•�e°+s a i�
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Dispasal System Form-Not for Voluntary Assessments
56 Route 6A (system in badc) (REVISED)
Propa�ty nddress
HUGHESJOANN
�^rt1ef O+.riersName
iMormation"s Yaftllouth
requiredforevery Wrt MA 02675 10l22/14
�age. �AYRoxn State Zip Code Drte of Irepedion
E. Report Completeness Checklist
� Inspection Summary:A, B, C, D, or E checked
� Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
� System Infortnation—Estimated depth to high groundwater
� Sketch of Sew.�qe D�posal System either drawn on p�qe 15 or attached in separete file
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