HomeMy WebLinkAboutTitle V Inspection Report - 767 JOHNSON STREET 7/29/2010 Commonwe-alth of Massachusetts
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Title 5, OnfickM 11inspecto H'con R
Subsueface Sewage Disposal Systern Form -Not for Voluritary Assessinents
1N SON S-7-., NO. ANDOVER, MA 01845
767 JO�
—-------------
Property Address
JOSEPH DIFRAIA
Owner ownwr-'s--Nanle f.
information i's NCB_ MA 01845 7/29/10
reqUirequired for
j ---------------------------—--- .......... -—----------------
every page. City(rown State Zip Code Date of Inspection
Inspection results most be submitted on this form. Inspection- d in any
way.
Important: A. General Information
When filling Out
o f
forms on the
001TIPLAter,use 1 Inspector:
only the tab key TOWN OFNORTH AWXWEK
��E. W IWIq
TM 7W
ALTH DEPAR 6
-r-7
to move your JAMES 1-1. CURRIER It HEALTH DEPARTMENT
cursor-(to not
use the return Marne of Inspector
key, J's SEPTIC & Dl,WN
Company Name
ens 131 FOREST ST.
Company Address
MIDDLE TON MA 01949
Cltyffown State Zip Code
978-774-6685
Telephone Number License Nurnber
----------
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, ace orate and coryIplete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper,function and Maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 6 (310 CMR M000). The system:
Passes El Co ndi tion ally Passes ❑ Fails
Needs Further Evaluation by the Local Approving Authority
2
7/29/10
p P -------
ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Flealth 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 Urne of inspection and tinder the conditions of use
at that time. This inspection does not address how the system will perform in the future tinder
the garne or different conditions of use.
TITLE V 2008.dov,•03/08 1 de 5 Official Inppction Fam"Stlb$AffhM SRWdVe DiSPOSA SY&telll-NW I Of 1
Commonwealth of Massachusetts
To'de 5 Official �nspecticn Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
767 JOHNSON ST., NO. ANDOVER, MA 01845
Property Address
JOSEPH DIFRAIA
Owner Owner's Name
information is
required for N® ANDOVER MA 01845 7/29/10
every page. CityfTown State Zip Code Date of Inspection
8. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/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 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM WORKING PROPERLY
B) System Conditionally Passes:
❑ one or ore System components as described in the "Conditional Pass"section need to be
replaced ,
ce d� repaired. The system, upon completion of the replacement or mpair, as approved by
the Board of"\Clalth,will pass.
Answer yes, no or note etermined (Y, N, ND) in the ❑ for the followi statements. If"not
determined,"please ex in.
❑ The septic tank is meta nd over 20 years old* or the se c tank(whether metal or not) is
structurally unsound, exhib substantial infiltration or iltration or tank failure is imminent.
System will pass inspection if e existing tank is rep ced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspectio ifiti structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is I than 20 years old is available.
ND Explain:
❑ Observation of sewage ackup or breakout or high static water lev in the distribution box due
to broken or obstruct pipe(s) or due to a broken, settled or uneven ribution box. System will
'r
pass inspection if 1th approval of Board of Health):
❑ broke pipe(s) are replaced
❑ o truction is removed
TITLE V 2008A9,t-03199 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
Commonwealth of Massachusetts
T'de 5 Offidal �nspecfion Form
�'3 E
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
767 JOHNSON ST., No. ANDOVER, MA 01846
Property Address ......
JOSEPH DIFRAIA
Owner Owner's Name
information is
required for NO ANDOVER MA 01845 7/29/10
every page. City(rown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The systle d
.T require pumping more than 4 times a year due to b- en or obstructed pipe(s). The
system wi I INass inspection if(with approval of the Board of He th):
❑ broken ipe(s) are replaced
❑ obstruction ' removed
ND Explain: 77x
C) Further Evaluation is Required by e Board of Health:
F-I Conditions exist which require fu er ev ation by the Board of Health in order to determine if
the system is failing to protect blic health,§afetly or the environment.
dq
1. System will pass unles oard of H Ith th tennines; in accordance with 310 CMR
16.303(1)(b)that the syst M is not functioning M,a manner which will protect public health,
safety and the environ ent:
❑ Cesspool or rivy is within 50 feet of a surface wate
❑ Cesspoo or privy is within 50 feet of a bordering vegetate wetland or a salt marsh
2. System 11 fail unless the Board of Health (and Public Water S lier, if any)
determine that the system is functioning in a manner that protects t public health,
protects�tylcl-
safety a environment: ,\\
❑ The system has a septic tank and soil absorption system (SAS) and the SA,,Q is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a publ water
supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private wat
supply well.
TIILE V 20018.dc-c-C3 vS -Iftla 55 official!")Speotrm"wiTI:Subbsuifface SvV aga Dlposol System z Page 3 VI 3
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
767 JOHNSON ST'., NO. ANDOVER, MA 01545
Property Address
JOSEPH DIFPAIA
Owner Owner's Name --
requiretionis NO. ANDOVER MA 01645 7/29/10
required for
every page. citylTown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further aluation is required by the Board of Health (coat.):
❑ The syste as a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a 'vate water supply well°.
Method used to determ distance:
This system passes if the well Xpresof performed at a DEP certified laboratory, for coliform
bacteria indicates absent and thmonia nitrogen and nitrate nitr ogen is equal to or
less than 5 ppm, provided that nteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
b
D) System 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 component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than "/day flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
® ❑ilc Any portion of cesspool or privy is within 100 feet of a surface water supply or
11 tributary to a surface water supply.
TITLE V 20WAm-03/08 Title 5 Official Inspection Form:Subsurface Seyvage Disposal System•page 4 of 4
Commonwealth of Massachusetts
TAle 5 Offic'W Inspection Form
Subsurface Sewage Disposal System Form -blot for Voluntary Assessments
767 JOHNSON ST., NO. ANDOVER, MA 01845
Property Address
JOSEPH DIFRAIA
Owner Owner's Name
information is
NO
required for . ANDOVER MA 01845 7/29/10
every page, City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ❑ i4l� 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. [This
system passes if the well water analysis, perforrined 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
and chain of custody must be attached to this formj
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
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.
E) Large Systems: To tae considered a large system the system must serve a facility with a
design flow of 10,000 g to 000,15 gpd.
'5'00'
For large systems, you must in i to either"yes"or"no"to each oft following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 f of surface drinking water supply
❑ ❑ the system is within 200 et of a ' utary to a surface drinking water supply
n El the system is locate in a nitrogen sans i e area (Interim Wellhead Protection
Area—IWPA) or mapped Zone 11 of a pu water supply well
S
system
S
system
te
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mis
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within within
system m i locate t
in
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""'' utary a surface drinking
s s/saTe nitrogen n area (Interim
water s 1)
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rog e s
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Area A mapped n I I of a pu wae supply IWP m pp Zone e 110 p
If you have answered "yes"to any uestion in Section E the system is sidered a significant threat,
I =
y Section
The ow r,
or answered "yes" in Section D ove the large system has failed. The ow or operator of any large
Section .I I
I e
system considered a signific t threat under Section E or failed under Section shall upgrade the
system in accordance wit 10 CMR 15.304. The system owner should contact th ropriate
regional office of the D artment-
7
TITLE V 2006,doc•03108 Title 5 Official Inspection Form'Substitlate SmhsUe Disposal System•Page 5 of 5
Commonwealth of a hu e
Title 5 Official Inspection Form
1 l 1
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
yp 767 JOHNSON ST., NO. ANDOVER, MA 01045
Property Address -- -- —
JOSEPH D1FRAIA
Owner Owner's Name
information i's
is
required for NO. ANDOVER MA 01045 7/29/10
every page. City/Town 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
® ❑ Pumping information 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 recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding 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 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 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))
TITLE V 2008.doo 03108 Trtte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
767 JOHNSON ST., NO, ANDOVER., MA 01645
Properly Address - -- ------ —_- —_
JOSEPH DIFRAIA
Owner Owner's Name
information is
required for NO. ANDOVER MA 01845 7/29/10
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 ------- Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
Number of current residents: 4
Does residence have a garbage grinder-? ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? jt ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
9$ GPD
Water meter readings, if available (last 2 years usage (gpd)): 206. —
Sump pump? ❑ Yes ® No
CURRENT
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Es lishment:
Design flow(based Yn X10 GMR 15.203): Gallons per (gpd)
Basis of design flow (seats/puns/sq.ft., etc.): p -----
Grease trap present? _ ❑ Yes ❑ No
Industrial waste holding tank present? A El Yes El No
Non-sanitary waste discharged to the T' 5 system? ❑ Yes ❑ No
Water meter readings, if availa
Last date of occupancy/: Date
ether(describe):
TITLE V 2008.doc-03/08 Title 5 Official Inspettion Form'Subsurface Sewage Disposal System•Page 7 of 7
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Subsurface Sewage Disposal System Form -Not for Vo|unt gryAssessments
7G7 JOHNSON ST..NO. ANDOVER, k8A0i845
-- pro`p e--Ad m-e s-s '------ --
J[)8EPH0FRAiA
Owner Owner's Name
mmnnatwn|o
required for NO. ANDOVER MA 81845 7/29/10
mmiypoUe. cfty(rown State Zip Code Date minspection
D. System Information (cont.) �
General Information
Pumping Records:
BuHREC{}R[}S' LPD11/B/2U00
G0un�/o�iDfVnnation� ------------------
Was system pumped en part of the inspection? Fl Yes ED No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: !
Type mfSystem:
0 Septic tank, distribution bmx, soil absorption system
Fl Single cesspool '
Lj
Overflow cesspool
LJ
Privy
Fl Shared system (yes or no) (if yes, attach previous inspection records, if any)
Fl Innovative/Aftemative 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 |/A system by system operator under contract
Fl
Tight tank. Attach a copy uf the DEPapproval. |
LJ Other(describe):
Approximate ago of all cornpononts, date installed (if known) and source of information.-
C C SIGNED OFF 10/22/1999
Were sewage odors detected when enivinc_Iat the site? Fl Yes 0 No
�h i`4 t;, A
_4V -` r f± ! -
Commonwealth of Massachusetts i_, ..
Title 5 Offildal InspectRon R
b Subsurface Sewage Disposal System Fortes -Not for Voluntary Assessments
w o' 767 JOHNSON ST., NO, ANDOVER, MA 01045
Property Address
JOSEPH DIFRAIA
Owner Owner's Name
information is
required for NO.ANDOVER MA 01545 7/29/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2' _ _---
taPt
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain).- -
Distance from private water supply well or suction line: 20'+teat
Comments (on condition of joints, venting, evidence of leakage, etc.):
PIPING IS BEHIND FINISHED WALLS
Septic 'Tank (locate on site plan):
"
Depth below grade: 15
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: yeas
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
------------------------------------------------------------------------------------------------------------------------
Dimensions:
10' X 5'8"- 1500 GAL.
- --- ---
Sludge depth:
2"- 5°
Distance from top of sludge to bottom of outlet tee or baffle 33
Scum thickness
3"
6"
Distance from top of scum to top of outlet tee or baffle __-
11"
Distance from bottom of scum to bottom of outlet tee or baffle ------- __---_- -_-_-__--
How were dimensions determined? SLUDGE JUDGE
TITLE V 2008.doc 03/08 Ttrte 5 Otttcfal 07SpecT7on Form Subsurface S&wvage Disposal System•Page 9 or 9
Commonwealth f Massachusetts
Title 5_ OfficlW Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•'� 767 JOHNSON ST., NO, ANDOVER, MA 01645
Property Address
JOSEPH DIFRAIA__
Owner Owner's Name
information is
required for NO. ANDOVER MA 01 845 7/29/10
- _
every page. City/Town State Zip Code Date of Inspection
D. System Information (font.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK IN GOOD CONDITION, TEES IN PLACE, TANK NOT READY FOR PUMPING
Grease Trap (locate on site plan):
epth below grade: feet ----- -
Mate ' I of construction:
❑ concret ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: — --- —
Scum thickness ° - ------ ----- ---
Distance from top of scum to top f outlet tee or baffle -----
Distance from bottom of scum to bottott of cutlet e or baffle
Date of last pumping:
Date
Comments (on pumping recommendati s, inl and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invet evidence ofeakage, etc.):
Tight or Holding Tank ank must be pumped at time of inspec n} (locate on site plan):
Depth below grade: - --
Material of con ruction:
❑ concret ❑ metal ❑ fiberglass ❑ polyethylene E ❑ other(explain):
TITLE V 2008.doc•03108 Title 5 Official Inspection Form:Subsu face Sewage Disposal System• e 10 of 10
Commonwealth of Massachusetts f
Title Official For
✓ 1',
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
707 JOHNSON ST., NO. ANDOVER, MA 01845
Property Address
JOSEPH DIFRAM
Owner Owner's Name
information is NO. ANDOVER MA 01545 7/29/10 _
required for _
every page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Tight or Iding Tang (cont.)
Dimensions:
Capacity: zagallons
Design Flow: gallons per day -
-- — -
Alarm present: ❑ Yes ❑ No
Alarm level.- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: --
Date
Comments (condition f alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
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 IN GOOD CONDITION, BOX 3" BELOW GRADE.
Pump Chamber Xorder: Ian):
Pumps in working ❑ Yes ❑ No
Alarms in working ❑ Yes ❑ No
TITLE v 200 8.doo-03108 Title 5 Official Inspection Form:Subsurface Seyeage Disposal System•Page 11 of 11
Commonwealth nwealth f Massachusetts
Title 5 Off"Icial Inspection Form
Subsurface Sewage Disposal System Form a Not for Voluntary Assessments _f "S''
767 JOHNSON ST., NO. ANDOVER, MA 01845
Property Address
JOSEPH DIFRAIA — —
Owner Owner's Blame
information is
required for NO ANDOVER MA—_— 01845 7/29/10
_ __— _
every page. citylrown State Zip Code Date of Inspection
D. System Information (cant.)
Comments (note condition of pump chamber, on on of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number: -
❑ leaching galleries number: --- —
❑ leaching trenches number, length:
® leaching fields number, dimensions:
ONE - 70'X24'
❑ overflow cesspool number: - --
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.);
NO SIGNS OF HYDRAULIC FAILURE, ALL VEGETATION LOOKS NORMAL.
TITLE V 2008.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts P'--
,DLU
Form
Title 5 Official Inspectiov
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
767 JOHNSON ST., NO. ANDOVER, MA 01845
Property Address
JOSEPH DIFRAIA
Owner Owner's Name
information is
required for NO ANDOVER MA 01845 7/29/10
every page. cityrrown State Zip Code Date of inspection
D. System Information (cont.)
Cesspo Is (Cesspool must be pumped as part of inspection) (locate on site plan):
Number an configuration
Depth —top of uid to inlet invert
Depth of solids lay
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, sign of hydrau failure, level of ponding, condition of vegetation,
etc):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note ondition of soil, signs of hydraulic failure, level of ponding, ndition of vegetation,
etc.):
TITLE V 2008.doo•03108 Title 5 Official Inspection FDnTi:Subsurface Sewage Disposal System•Page 13 of 13
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Subsu face Sewage Disposal System Co ®Not for Voluntary Assessments
!� 767 JOHNSON ST., NO, ANDOVER, MA 01345
Property Address
JOSEPH DIERAIA
Owner Owner's Name
information is
required for NO. ANDOVER MA 01345 7/29/10
—
every page. CihdTown, State Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
TITLE V 2008.doo•03106 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
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. _ Subsurface Sewage Disposal Systems Form Not for Voluntary Assessments
J 767 JOHNSON ST., NO. ANDOVER, MA 01845
Property Address _ - -- -----
JOSEPH DIFRAIA
Owner ----- -- -- -- - ---- -- - -_ _------- --__ ---
owner's Name
information is
required for NO. ANDOVER MA 01645 7/29/10
every page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 5' --- - --------
feet
Please indicate all methods used to determine the high ground water elevation:
® obtained from system design plans on record
If checked, date of design plan reviewed: 12129/1997 _
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USOS database- explain:
You must describe how you established the high ground water elevation:
TEST PIT DATA ON FILE WITH BOH. — - -- - -
TITLE V 20M doc-03108 Title 5 Official Insoection Form:Subsurface Sew-atte Disoosal Svstem•Page 15 of 15