HomeMy WebLinkAboutInspection Report 2023 May 9fr,, Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth 02664 5-9-23
City/Town State Zip Code Date of lnspection
lnspection results must be submitted on this form. lnspection forms may not be altered in any
way. PIease see completeness checklist at the end of the form.
lfilffi::i':,H!"' A. lnspector lnformation
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
lVichael Sears
Name of lnspector
Robert B Our Co lNC.
Company Name
363 Whites Path
nAI t o'luz3
HEALTH DEPI
Company Address
South Yarmouth Ma 02664
City/Town
508-477-8877
State
st14430
Zip Code
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. I Passes
2. E Conditionally Passes
" MICHAEL
3. E Needs Further Evaluation by the Local Approving Authority SEARS
No. SI1
4. E raits
5-9-23
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. lf the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
tsinsp.doc . teu. 7 12612018 Title 5 Otficial lnspection Form: Subsurface Sewage Disposal System. Pags'l of 18
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5s. Commonweatth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma. 02664 5-9-23
City/Town State Zip Code Date of lnspection
C. lnspection Summary
lnspection Summary: Complete 1,2,3, or 5 and all ol 4 and 6.
1) System Passes:
X I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in working order
2l System Conditionally Passes:
n 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.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. lf "not
determined," please explain.
The septic tank is metal and over 20 years old* or the 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
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.
nV trN Etrto(Exptainbetow):
t5insp.doc . rev. 7 12612018 Titl6 5 Official lnspection Form: Subsurface Sewage Disposal System . Pags 2 of 18
5fu. Commonwealth of Massachusetts
Title 5 Official lnspection Form
subsurface sewage Disposal system Form - Not for Voluntary Assessments
415 Pine St.
Property Address
[Vlaureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth 02664 5-9-23
City/Town State Zip Code Date of Inspection
C. lnspection Summary (cont.)
2l System Conditionally Passes (cont.):
n pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
E 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):
tr broken pipe(s)are replaced n V n f.f E frfO (Exptain betow):
! obstruction is removed tr V tr U E ruO (Exptain betow):
tr distribution box is leveted or reptaced n y n ru E ruo (Explain betow):
n ffre 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):
tr broken pipe(s) are reptaced n V n frf E ruO (Exptain betow):
n obstruction is removed ! V tr trt n ruO (Exptain betow):
3) Further Evaluation is Required by the Board of Health:
E 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1Xb) that the system is not functioning in a manner which will protect public health,
safety and the environment:
t\/a
tSinsp.doc . (ev. 7 1261201 I Title 5 Official lnspection Form: Subsurface Sewage Disposal System. Page 3 of 18
5s. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
N/laureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 5-9-23
City/Town State Zip Code Date of lnspection
C. lnspection Summary (cont.)
t] Cesspool or privy is within 50 feet of a surface water
n Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. 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:
! fne 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.! fne system has a septic tank and SAS and the SAS is within aZone 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.
f] fne 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**.
IVIethod used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent 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.
c. Other:
4l System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
T-t rvt Backup of sewage into facility or system component due to overloaded orr-r rar clogged SAS or cesspool
Tl ty1 Discharge or ponding of effluent to the surface of the ground or surface watersH a due to an overloaded or clogged SAS or cesspool
tsinsp.doc. rev. 712612018 Title 5 Official lnspection Form: Subsurface Sewage Disposal System . Page 4 of 18
5s' Gommonwealth of Massachusetts
Title 5 Official Inspection Form
subsurface sewage Disposal system Form - Not for Voluntary Assessments
415 Pine St.
Property Address
il/aureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
Ma.02664 5-9-23
State Zip Code Date of Inspection
C. lnspection Summary (cont.)
4l System Failure Criteria Applicable to Al! Systems: (cont.)
Yes No
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 lessthan/, day flow
Required pumping more than 4 times in the last year IVOf 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 water supply.
Any portion of a cesspool or privy is within aZone 1 of a public water supply
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. [Thissystem passes if the well water analysis, performed at a DEp certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.l
The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
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 failure.
5) Large Systems: To be considered a large system the system must serve a facility with adesign 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 thequestions in Section C.4.
Yes No
n 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 (lnterim Wellhead Protection
Area - IWPA) or a mapped Zone ll of a public water supply well
Title 5 Official lnspection Fom: Subsurface Sewage Disposal System . Page 5 of 18
x
n
x
x
x
tr
n
x
x
tsinsp doc ' rcv.712612018
tr
u
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
subsurface sewage Disposal system Form - Not for voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma.02664 5-9-23
State Zip Code Date of lnspectionCity/Town
6.
C. lnspection Summary (cont.)
lf you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CI\4R 15.304. The system owner
should contact the appropriate regional office of the Department.
You must indicate "yes" or "no" for each of the following lor alt inspections:
Yes No
X n Pumping information was provided by the owner, occupant, or Board of Health
tr X Were any of the system components pumped out in the previous two weeks?
X n Has the system received normalflows in the previous two week period?
tr X ilffiiT!;[?umes of water been introduced to the system recently or as part of
X n H:ffi?:[*.,il1,re svstem obtained and examined? (lf they were not
X n Was the facility or dwelling inspected for signs of sewage back up?
X tr Was the site inspected for signs of break out?
X tr Were allsystem components, excluding the SAS, located on site?
X n 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?
x
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:
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(5)]x
t5insp.doc . rcv. 7 l26nUB Title 5 Official Inspection Form: Subsurface Sewage Disposal System ' Page 6 of 18
tr
5fu. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
pa9e
Owneis Name
South Yarmouth Ma 02664 5-9-23
City/Town State Zip Code Date of lnspection
D. System lnformation
1. Residential FIow Conditions:
Number of bedrooms (design)J Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms)
Description:
2
330
2Number of current residents:
Does residence have a garbage grinder?
Does residence have a water treatment unit?
lf yes, discharges to:
ls laundry on a separate sewage system? (lnclude laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd))
Detail:
fl Yes X No
EyesX No
EvesXI No
!YesX No
EYesX No
2021- 58000 gal
2022- 47000 gal
Sump pump?
Last date of occupancy:
EvesX No
Present
Date
tsinsp.doc. rcv. 7 12612018 Title 5 Official lnspection Fom: Subsurface Sewage Disposal System ' Page 7 of 18
5ft. Commonwealth of Massachusetts
Title 5 Official lnspection Form
subsurface sewage Disposal system Form - Not for voluntary Assessments
415 Pine St.
Property Address
lvlaureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 5-9-23
State Zip Code Date of lnspectionCity/Town
D. System lnformation (cont.)
2. Commercial/lndustrial FlowConditions:
Type of Establishment:
Design flow (based on 310 CI\/R 15.203):
Basis of design flow (seats/persons/sq.ft., etc.)
Grease trap present?
Water treatment unit present?
lf yes, discharges to:
lndustrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe below):
Gallons per day (gpd)
EyesE No
EvesI No
Eves! No
EyesE No
Date
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection?
lf yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
7-12-18
nvesX No
gallons
tsinsp.doc. rev. 712612018 Title 5 Offlcial lnspection Form: Subsurface Sewage Disposal System . Page I of 18
5$. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
IVIaureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma. 02664 5-9-23
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
4. Type of System:
X Septic tank, distribution box, soil absorption system
tr Single cesspool
tr Overflow cesspool
tr Privy
tr Shared system (yes or no) (if yes, attach previous inspection records, if any)
n Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the l/A system by system operator under contract
n Tight tank. Attach a copy of the DEP approvat.
tr Other (describe):
Approximate age of all components, date installed (if known) and source of information
8-9-02 # 02-291
Were sewage odors detected when arriving at the site?
5. Building Sewer (locate on site plan):
Depth below grade:
Material of construction :
f]cast iron X aO pVC E other (exptain)
Distance from private water supply well or suction line:
EyesX No
25"
feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)
tsinsp.doc. tev. 7 12612018 Title 5 Official lnspection Fom: Subsurface Sewage Disposal System ' Page 9 of 18
5ft. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
Ma.02664 5-9-23
State Zip Code Date of lnspection
D. System lnformation (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
Material of construction :
[tconcrete E metal
1500 gal
15"
n fiberglass n polyethylene I other (explain)
feet
lf tank is metal, list age years
ls age confirmed by a Certificate of Compliance? (attach a copy of certificate) tr Yes E No
Dimensions:
Sludge depth:
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
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
1 500
2"
28"
0
8"
18"
Sludge judge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gal tank with in tee and out tees in place, all covers are at grade
tsinsp.doc. (ev. 7 12612018 Title 5 Official lnspection Form: Subsurface Sewage Disposal System . Page 10 of 18
5ft' Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth
City/Town
Ma 02664 5-9-23State Zip Code Date of lnspection
D. System lnformation (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
lVlaterial of construction :
I concrete E metal I fiberglass f] polyethylene E other (explain):
feet
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:Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
lVlaterial of construction :
f]concrete E metal I fibergtass n polyethylene E other (explain):
Dimensions:
Capacity:
Design Flow:
gallons
gallons per day
Title 5 Official lnspection Form: Subsurface Sewage Oisposal System . Page 1 1 of 1 8tsinsp.doc. @v. 7 12612018
5fu' Gommonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Prope(y Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma.02664 5-9-23
City/Town State Zip Code Date of Inspection
D. System lnformation (cont.)
8. Tight or Holding Tank (cont.)
Eyes nruo
Alarm in working order:
Date
E Yes I tto
Comments (condition of alarm and float switches, etc.)
* Attach copy of current pumping contract (required). ls copy attached? E yes E ruo
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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 16x16 with 2 outlet lines, cover is 6" below grade
t5insp.doc' rcv. 7 1261201 I Title 5 Official lnspection Form: Subsurface Sewage DisPosal System'Page 12 of 18
AIarm present:
Alarm level:
Date of last pumping:
5\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth lr/a.02664 5-9-23
City/Town State Zip Code Date of lnspection
D. System lnformation (cont.)
10. Pump Chamber (locate on site plan):
Pumps in working order: E yes n No.
Alarms in working order: fl yes f] No.
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.).
* lf pumps or alarms are not in working order, system is a conditional pass.
1 1. soil Absorption system (sAS) (locate on site plan, excavation not required):
lf SAS not located, explain why:
Type:
!
x
tr
tr
tr
n
tr
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/alternative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions
number:
2
tsinsp.doc . rcv. 7 1261201 I Title 5 Official lnspection Form: Subsurface Sewage Disposal System . Page 13 of 18
5fu. Commonwealth of Massachusetts
Title 5 Official Inspection Form
subsurface sewage Disposal system Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 5-9-23
CityiTown State Zip Code Date of lnspection
D. System lnformation (cont.)
11. SoilAbsorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 2- 500 gal Drywells, chambers are clean and dry with no sign of failure
12. 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
lndication of groundwater inflow n yes n ruo
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc. rev. 7 12612018 Title 5 Official lnspection Form: Subsurface Sewage Disposal System . page .t4 of 18
5s. Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma.02664 5-9-23
CityiTown State Zip Code Date of lnspection
D. System lnformation (cont,)
13. Privy (locate on site plan):
lMaterials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc . rev. 712612018 Title 5 Official lnspection Form: Subsurface Sewage Disposal System . Page 1S of 18
6:,, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for every
page.City/Town
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
rESS
Dionne
Owner's Name
South Yarmouth Ma 02664 5-9-23
oitci ot inspectionState Zip Code
D. System lnformation (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view 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. Check one of the boxes below:
XT hand-sketch in the area below
drawing attached separately
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15insp.doc . rev. 7/26/2018 Title 5 Official lnspection Form: Subsurfacs Sewags Disposal System ' Page 16 of 18
5s. Commonwealth of Massachusetts
Title 5 Official lnspection Form
subsurface sewage Disposal system Form - Not for Voluntary Assessments
415 Pine St.
Property Address
[Vlaureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma.02664 5-9-23
CitylTown Zip Code Date of lnspection
D. System lnformation (cont.)
15. Site Exam:
I Check Stope
X Surface water
[l Check cettar
X Shauow weils
Estimated depth to high ground water:10'+
feet
Please indicate all methods used to determine the high ground water elevation:
X Obtained from system design plans on record
7-18-02lf checked, date of design plan reviewed Date
n Observed site (abutting propefi/observation hole within 150 feet of SAS)
n Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
tr
tr
You must describe how you established the high ground water elevation
No ground water per plan
Before filing this lnspection Report, please see Report Compteteness Checklist on next page.
l5insp.doc. rev. 7 12612018 Title 5 Official lnspection Form: Subsurface Sewage Disposal System . page 17 of 18
State
5$' Commonwealth 6f Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
415 Pine St.
Property Address
Maureen Dionne
Owner
information is
required for every
page.
Owner's Name
South Yarmouth Ma 02664 5-9-23
City/Town State Zip Code Date of lnspection
E. Report Completeness Checklist
Gomplete all applicable sections of this form inclusive of:
X n lnspector lnformation: Complete allfields in this section.
X g. Certification: Signed & Dated and 1, 2,3, or 4 checked
X C. lnspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
X O. System lnformation:
For 8: TighVHolding Tank - Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc . rev. 7 12612018 Title 5 Official lnspection Form: Subsurface Sewage Disposal System. Page 18 of 18