HomeMy WebLinkAboutInspection Report 2015 May 07 . M � .T,� �
� � Commonwealth of Massachusetts P�'J G3C�C'r,�0�9[�DD
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form -Not for Voluntary Assessments MAY I $ (��,rj
' 25 Vacation Ln HEALTH DEPT.
PropeRy Address G�.� ��
Aditi Joshi -�'� ����
Owner Owner's Name '"", .�x „x y�r
intwmation is Yarmouth MA 02664 5-7-15
requiretl fa every
page. Cdy/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy
Name.4[�pspecter--------�—�
Upper Cape Septic Services
CompanyName
P.O. Box 73
Company Address
E. Falmouth MA 02536
Citylfown State Zip Code
1-508-485-0905 S13971
Telephone Number License Number
B. Certification
I ceAify that I have personally inspected the sewage disposal system at this address and that the
infortnation reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my training and ex�rience in the proper fundion and mairitenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Trtle 5 (310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes � Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-7-15
Inspector's Signature Date
The system inspector shall submit a copy of this inspedion 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 repoR only describes conditions at the tirr�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.
tsns•a�3 Titla 5 Oficiel bispecGon Fwm'Su�urtace Scwage Oisposal S�stan•P.ge 1 d 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
5ubsurtace Sewage Disposal System Form -Not for Voluntary Assessments ,
25 Vacation Ln
Property Address
Aditi Joshi
�� Owner's Name
information is Yamtotrth MA 02664 5-7-15
required for every
�9e. City/Town State Zip Code Date W Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E J always complete all of Section D
A) System Passes:
❑ 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 exisf.Any failure criteria not eGaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
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) is structurally
unsound, exhibits substantiai infiRrafion or e�Ifration o�Tank fiailure is imminenf.System will pass
inspection if the ewsting tank is replaced with a complying septic tank as approved by the Boarci of
HeaNh.
*A metal septic tank will pass inspection if it is struclurally sound, not leaking and if a Cert�cate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (F_xplain below):
i5ins-3M3 TNe 5 Official Inspection Fam:Subsurtace Scwape Disposal Sysbm•Page 2 M 17
� � Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurtace Sewage Disposal System Form -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Joshi
�^'�� Owner's Name
inf«mation is Yafmouth MA 02664 5-7-15
required for every
�9e. CitylTown Stffie 2ip Code Date of Inspedion
B. Certification (cont.)
❑ Pump Chamber pumps/alartns not operational. System will pass with Board of Heatth approval if
pumps/alartns are repaired.
B) System Conditionally Passes (coM.):
❑ Obseivation 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 distribuUon box Sys[em will
pass inspection if(with approval of Board of HeaRh):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain 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 HeaRh):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (E�cplain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaivation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Heafth in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Heakh determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public heakh,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 7Ne 5 Offidal InspecEan Fwm_SuEsurtace Sewage Disposal Sysbm•Pege 3 d 1]
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface 3ewage Disposai System Form -Not for VoluMary Assessments '
25 Vacation Ln
Property Address
Aditi Joshi
Owner Owner's Name
information is Yarmouth MA 02664 57-15
required fa every
�9e. Ci[y/Town State 2ip Code Date of Inspection
B. Certification (cont.�
2. System wiii fail unless the Board of Heakh (and Public Water Supplier, if any)
detertnines that the system is functioning in a manner that protects the public heatth,
safety and environmeM:
❑ 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 surface wate�suppiy.--_- _ -
❑ 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 ihe SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to detertnine 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 fortn.
3. Other:
D) System Failure Criteria Appticable to Ail Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
� � Backup of sewage into facility or system component due to overioaded or
clogged SAS or cesspool
� � Discharge or ponding of effiuent to the surface 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 overioaded
or clogged SAS or cesspool
� � Liquid depth in cesspool is less than 6° below invert or available volume is less
than Y:day flow
t5ins•3/73 Title 5 Otficial Inspection Form'Subsurface Sexage Dsposal System•Pege 4 d 17
i
I � � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form -Not for Voluntary AssessmeMs
25 Vacation Ln
Property Address
Aditi Joshi
Owner Owner's Name
infamation is Yemlouth MA 02664 5-7-15
required fa every
�9e. City/Town State Zip Code Date of Inspection
B. Certification (cont.>
Yes No
� � Required pumping more than 4 times in the last year NOT due to dogged 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 surtace water supply or
tributary to a surtace water suppiy.
❑ � Any portion of a cessFmol or privy is within a Zone 1 of a public well.
❑ � Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ � Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [fhis
system passes if the well water analysis, pertormed at a DEP certified
laboratory,for fecal col'rfortn bacteria indicates absent and the presence
of ammonia nkrogen and nitrate nitrogen is equai to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this 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 ewst as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Boarci of Heafth to deteRnine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 70,000 gpd to 15,000 gpd.
For large systems, you must indicate ekher"yes" or"no"to each of the following, in addHion to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 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 located in a nRrogen 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 Sedion E the system is considered a significant threat,
or answered "yes" in Sedion 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.
t5ir�s•3H3 TNe 5 Olftt:ial InspecUon Fwm�Subcurtace Se.vage Disposal Sysbm•Page 5 of 7�
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form -Not for Voluntary Assessmerrts
25 Vacation Ln
Property Address
Aditi Joshi
�'�� Owner's Name
intwmation is Yarmouth MA 02664 5-7-15
required for every
page. Cltylfown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate'yes"or"no"as to each of the following:
Yes No
� ❑ Pum�ng infoRnation was provided by the owner, occupant, or Board of Health
❑ � 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 recerrtly or as part of
this inspection?
� � Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
� ❑ Was the facility or dwelling inspected for signs of sewage back up?
� ❑ Was the site inspected for signs of break out?
� ❑ Were all system components, exGuding the SAS, located on site?
� ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of�iquid, 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 and location of the Soil Absorption System (SAS)on the site has
been detertnined based on:
❑ � Existing information. For example, a plan at the Board of Health.
� � Detertnined in the field (f 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
Residential Flow Conditions:
Number of bedrooms(design): z Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Z20
t5irs•3113 Title 5 OfFicial Inspection Fortn:SuOsurtace Seaege Drsposnl SryRm•Page 8 M 17
� � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Fortn -Not for Voluntary Assessments
' 25 Vacation Ln
Property Address
Aditi Joshi
Owner Owner's Name
intwmation is Yatmouth MA 02664 5-7-15
required fw every
page. City/Town State Zip Code Date ot Inspection
D. System Information
Description:
Number of current residents:
0
Does residence have a garbage grindeR ❑ Yes � No
Is laundry on a separate sewage system? (InGude laundry system inspection � Yes � No
infoRnffiion in this report.)
Laundry system inspected? ❑ Yes � No
Seasonal use? � Yes ❑ No
Water meter readings, 'rf available past 2 years usage (gpd)): 5� � °'? �j
Detail:
Sump pump? ❑ Yes � No
Last date of occupancy: 5-2015
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 340 CMR 15.203): �iions Per day�9Pe>
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank preserrt? ❑ Yes ❑ No
Non-sanitary waste discharged to the TiUe 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 7Ne 5 dfival I�n Fwm:Subsurtace Scwage Dsposal SysMn•Paga 7 d 77
� Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Fortn -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Joshi
Owner pwner's Name
information's Y9mlouth MA 02664 5-7-15
requireA for every
Pa9e. City/Town Stffie Zip Code Date of Inspection
D. System Information �cont.�
Last date of occupancy/use: oa�e
Other{describe below):
General information
Pumping Records:
Source of information: Owner—pumped 2013
Was system pumped as part of the inspection? ❑ Yes � No
If yes, volume pumped: 9ano�s
How was quantity pumped detertnined?
Reason for pumping: Maintenance
Type of System:
❑ Septic tank,distribution box, soil absorption system
� Single cesspool
� Overflow cess�wol
❑ Privy
❑ Shared system (yes or no) (f yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3H3 TNa 5 Officid InspecEon Fortn:Subsurtace Se�rage Dspual SysEem•Page 8 of 17 �.
,
� � Commonwealth of Massachusetts
Title 5 Oificial Inspection Form
Subsurface Sewage Disposal System Fortn -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Joshi
�'^'�� Owner's Name
infamation is Yartnouth MA 02664 5-7-15
required fa every
page. ��YR� State Zip Code Date of Inspection
D. System Information (cont.)
Approuimate age of all components, date installed �f known) and source of information:
1960's
Were sewage odors detected when arriving at the site? ❑ Yes � No
Building Sewer(locate on sRe plan):
Depth below grade: z4�
feet
Material of constivction:
� cast iron � 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: �e�
Comments (on conditian ofjoints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(loca[e on site plan):
Depth below grade: teet
Material of constniction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(expiain)
If tank is metal, list age: ree�
Is age confiRned by a Certificate of Compliance? (attach a copy of cert�cate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
5iris•3/13 Title 5 qficial Ins .
pecEon Form:SuFeurface Saxege Dspostl Sya4nn•Page 9 N 77
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
3ubsurtace Sewage Disposal System Fortn -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Joshi
�� Owner's Name
infamation is Yefmouth MA 02664 5-7-15
required fa every
�9e �gyRay� State Zip Code Date of i�pection
D. System Information (cont.)
Septic Tank(corrt.)
Distance from top of sludge to bottom of oudet tee or baH1e
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?
Comments(on pumping recommendations, inlet and outlet tee or baftle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap Qocate on site plan):
Depth below grade: teec
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 baftle
Date of Iast pumping: oa[e
15iris•3�13 TNe 5 Official lnspection Form:Su�urface SeNege Dsposal SysEam•Page 10 M 77
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal3ystem Fortn -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Jashi
�'�� Owner's Name
iMormation is Ya�7nouth MA 02664 5-7-15
required for every
page. ��YR� State Zip Code Date o/Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (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 per day
Alartri present: ❑ Yes ❑ No
Alartn level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: oate
Comments (condition of alaRn and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
l5iris•3/13 rme s omc�mw�o�,wrm:s��rt�s��osa�i s�sg+r�•weo t i a i�
� Commonwealth of Massachusetts
Titie 5 Official inspection Form
3ubsurface Sewage Disposal System Fortn -Not for Voluntary Assessments '
25 Vacation Ln
Property Address
Aditi Joshi
Owner p�er�s Name
iMwmation is Ya�7nouth MA 02664 5-7-15
required for every
�ye. CitylTowm State Zip Cotle Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) pocate on site plan):
Depth of liquid level above outlet invert
Commenis (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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
` If pumps or alanns are not in woricing order, system is a conditional pass. '
Soii Absorption System (SAS) pocate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•'J73 TNe 5 Ofieid Irepection Form:Subsurtace Se.vage Disposel S)sRm•Pege 12�17 ��
� � Commonwealth of Massachusetts
Title 5 Official Ins ection Form
p
Subsurtace Sewage Disposal System Form-Not for Volurrtary Assessmerrts
'" 25 Vacation Ln
I Property Address
! Aditi Joshi
�'^� Owner's Name
infwmation is Yartitouth MA 02664 5-7-15
required for every
page. ��Y�T� State Zip Code Dffie W Inspection
D. System Information (cont.)
Type:
❑ leaching pits number.
❑ leaching chambers �umber: —
❑ leaching gaileries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
' � overtiow cesspool number: �
❑ innovative/atternative system
Typelname of technology:
Comments(note condition of soil, signs of hydraulic failure, tevel of ponding,damp soil, condition of
vegetation, etc.):
Overtlow cesspool shows signs of failure with stain line at inlet invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2-Inline
Depth–top of liquid to inlet invert N/A Empty
Depth of solids layer N!A Em�y
Depth of scum layer N/A Empty
Dimensions of cesspool Sx5
Materials of construction Block
Indication of groundwater inflow ❑ Yes � No
�*�•��a rne s o�w i
nspecAon Form:Subwrtxe Sewage Dsposal Systam•P�e 73 W 1�
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Fortn -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Joshi
Owner Owner's Name
inrormation is Yarmouth MA 02664 5-7-15
required fa every
�9e ��y/ray,T State Zip Code Dffie of Inspec4ion
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Both cesspools were empty at inspection with stain line in second cesspool at inlet invert. Both
cesspools show structural issues with blocks that have started to shift.
Privy pocate on ske plan):
Materials of constniction: �
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condftion of vegetation,
etc.):
t5iris•3�'13 Title 5 Official Inspectian Form:Subsufiace Sewaga Dspcsal SysEern•P;ga 14 M il
i .
� � � Commonwealth of Massachusetts
Title 5 Official Inspection Form �( (�
, Subsurtace Sewage Disposal System Fortn -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Joshi
Owner Owner's Name
iniwmation is Y8f7T�outh MA 02664 5-7-15
required for every
page. ��YRa'r+� State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two perrnanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the tmxes below:
� hand-sketch in the area below
❑ drawing attached separately
�
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�j r� � Y
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�sms•a�ia rme s o�y ms
pecfian Form:Subwrface Sw,aga Dsposal u�m•Page 15 of 77
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments ,
25 Vacation Ln '
Property Address
AdftiJoshi
�� Owner's Name
irttamation is Ya�inouth MA 02664 5-7-15
required fa every
page. ��HRa� Stffie Zip Code Date of Inspeetion
D. System Information (cont.)
Site Ezam: ,
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated de h to hi h round water: �z
pt 9 9 feet
�
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on recorcl
If checked, date of design plan reviewed: oace �
� Observed site (abutting property/obsenration 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 descri� how you established the high ground water elevation:
USGS and town maps show groundwater at greater than12'.
Before filing this Inspection Report, please see Report Completeness Checklist on ne�ct page.
�;,,�•y�3 TNe 5 Olficial Inspection Form:Subsurtace Sexage D�posal Sysfern•Page 78 oF 17
r
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 25 Vacation Ln
; Property Address
Aditi Joshi
� �ef Owner's Name
�' in�famation is ry YBfRlOuth
i r uired for eve MA 02664 5-7-15
� page. City/Town State 2ip Code Dffie of Inspection
' E. Report Completeness Checklist
� Inspection Summary:A, B, C, D, or E checked
� Inspection Summary D (System Failure Criteria Applicable to All Systems) compieted
� System Infortnation—Estimated depth to high groundwater
� Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
15ins•3M3
TMe 5 OfficiallnspeeEon Fwm:SuhsuKace Sewage Daposal S}sbm•Ptpe 17 af i7