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HomeMy WebLinkAboutTitle V Inspection Report - 531 FOREST STREET 7/17/2010 uM � Commonwealth of Massachusetts Title 5 Official For -Inspection Form Voluntar sessments Subsurface Sewage Disposal System Foy„ e _ F Y _ T � 531 Forest ` Pro Address ert __.-- p y — �— -- ...---- — Coca Earl &Associates Owner Owner's Name " information Is North Andover Ma. 01845 — 7-17-20 0 1� required for every _._ _-. _ page. City/Town State Zip Code Date of In pection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When A General Information out forms ° on the computer, use only the tab 1. Inspector: key to move your t VL cursor-do not F. Paul Cardone use the return _ ..._.. - — — — --- key. Name of Inspector "s.l Septic Com _liance, Inc. ee Company Name 447 Boston Street t ki4k f lh N P Company Address e Topsfleld Ma. 01983 City/Town State Zip Code 978-407-1808 978-681-0726 3294 Telephone Number License Number B. Certification 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. I 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 E,alu ion by,thel-cal Approving Authority C, tor s Signature In�p� mow.,,°~-- ..M,�w,� ---- -- ' 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. 531 Forest St No.andover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Official Title 5 i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early &Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection B. 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: 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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 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. ND Explain: ❑ 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed 531 Forest St No.andover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early&Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, 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 2. 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: ❑ The 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 531 Forest St No.andover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title I Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early &Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: 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: ❑ ® 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. 531 Forest St No.andover me 7-17-10 coco early-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early &Associates Owner Owner's Name information is North Andover Ma. 01845 7-17-2010 required for 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. ❑ ❑ 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, 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® El 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 be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the 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 drinking water supply ❑ ❑ the system is located in a nitrogen 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 Section E the system is considered a significant threat, or answered "yes" in Section 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. 531 Forest St No.andover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco Early&Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 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)] 531 Forest St No.anclover ma 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early &Associates Owner Owner's Name information is North Andover required for every Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 Number of current residents: 5 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? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 531 Forest St No.andover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early &Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Last pump on file 7-19-06 Emergency pump 9-7-05 1800gallons 1000 tank 800 pump chamber j Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Pump truck tube Reason for pumping: To properly inspect structural integrity of the tank,and baffles Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El maintenance technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: According to report on file,built in 1977 Were sewage odors detected when arriving at the site? ❑ Yes ® No 531 Forest St No.anclover me 7-17-10 coco early•08106 Title 5 Official Inspection Fcrm:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form o Not for Voluntary Assessments 531 Forest Property Address Coco,Early&Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): looked in OK condition A old system ) Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1" 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? Septic Dip-Stick 531 Forest St No.andover ma 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early &Associates Owner Owner's Name information is North Andover Ma. 01845 7-17-2010 required for every page. City/Town State Zip Code Date of 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.): We recommend tank be pumped on a yearly basis, Baffles are deteriorating, we recommend sanitary tee's pvc be put on,level was ok,no apparent leakage. } I Grease Trap (locate on site plan): I N/A Depth below grade: feet 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 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 531 Forest St No.andover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early&Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: N/A Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: date Comments (condition of 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 Even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in need of replacement deteriorating around pipes,some carryover,distribution appeared to be equal. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No 531 Forest St No.andover ma 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early&Associates Owner Owner's Name information is North Andover required for every Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Some solids in pump chamber,chamber itself ok, pump works, wires in chamber need to be tied up according to the pumper. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 shallow pits ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ 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.): yard area stoney none none no grassy front 531 Forest St No.andover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 '.. Commonwealth of Massachusetts Official Title 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early&Associates Owner Owner's Name information is North Andover Ma. 01845 7-17-2010 required for every — — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth —top of liquid to inlet invert Depth of solids layer - Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 531 Forest St No.andover ma 7-17-10 coco early•06/06 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 531 Forest StreetNorth Andover,MA 01845 Owner's Name: Michael Ciofolo Date of Inspection: November 8,2006 SKETCH OT 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. � WELL P i s i AtJ CZ 57 2-1 tsL— S �— D1Fa 38. 3 } l - 1 / A� 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM[ PART C SYSTEM INFORMATION(continued) Property Address: 531 Forest Street North Andover,MA 01845 Owner's Name: Michael Ciofolo Date of hispection: November 8,2006 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. � WELL p �s i Ar..lL:cs V 100 •4- TO l ecut� P,k �.��.,s�• Z o b q4.0 1 Ir Commonwealth of Massachusetts Official Title 5 i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early&Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 531 Forest St No.anclover me 7-17-10 coco early•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 531 Forest Property Address Coco,Early &Associates Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 6 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: 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 USGS database- explain: You must describe how you established the high ground water elevation: Took info. of of report on file dating 11-8-06,basement was dry, no sump The house had a garbage grinder,system not designed for one also had a water softener,we recommend softener be leached to a separate area not in main system. At the time of the inspection the bottom of the pipe to the top of the liquid in the pit was 2" not enough separation need atleast 6" 531 Forest St No.andover me 7-17-10 coco early-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 '., Nair M WAff M mr JCKVItrC THE PROFESSIONAL EXPERTS IN THE SEPTIC & DRAIN INDUSTRY PLEASE PAY FROM THIS BILL- ;tomer Name: 7 CHISHOLM ROAD vice Location: KINGSTON, NH 03848 (603)329-6005- (978)374-8803 )ne: (978)921-5353•(978)465-2121 •(603)772-2759 itact: www.boraczekseptic.com RESIDENTIAL / COMMERCIAL •ng Address: SERVICING THE ENTIRE NORTH SHORE Zip: CERTIFIED TITLE V INSPECTORS /Vo SAME DAY EMERGENCY SERVICE e of Service: Nature of Service Special Instructions ❑Completed BIReg. Maint. 0 Incomplete Reason: Per:_. 0 Schedule: 'g. ❑Emergency C JJ-0ay ❑Night AM/-.PM ,rvices Rendered 0 Car Wash ,uum Pumping ❑Dump Charges �eptiG Tank minimum 5,=s of sand Observations Drain Cleaning irywell $ /ton+9%fuel ❑Zood Condition 0 Main Line each Pit/Overflow surcharge.Any amount over 0 Leach field Runback 0 Toilet Bowl ,-Box 5 tons will be billed. 0 Riding High 0 Kitchen Sink ump Chamber (liquid level) 0 Bathtub/Shower irease Trap 0 Yearly Profile Fee 11 Full to Cover 0 Vanity :atch Basin ❑Excessive Solids ❑Floor Drain ortable Toilet ❑Boraczek Charges Top/Bottom ❑Yard Drain ether 4 hour minimum 0 Use No Powdered Soap 0 Vent )ty: 1 hour travel ❑Heavy Grease' 0 Water Jetting 'ize: 0 Roots 0 Other 0 Suggest Electri6 Rootering 0 Footage: Inder1000gaII6ns ❑W1000gallons 01500gallons 0 Van Called, 000 gallons ❑3000 gallons 0 4000 gallons 0 Other 000 gallons 0 6000 gallons 0 other scellaneous igging Charge 0 BaGkhoe 0 Inspection ocation ft.I in. 0 Kubota hrs. 0 Title V Inspection ervice Call 0 Consultation Reason: abor 0 Estimate 11 Pump Repair /ailing Time 0 System Installation ❑Repair 0 Portable Toilet Rental D System Treatment jging Charge Is Per Driver's Discretion 0 Baffle 0 Rejuvenation ,scription of Work commendations Terms of Payment: C.O.D. PARTS uum Pumping Drain Cleaning Payment Requireq.ppon Service TAX _ I16­ck —Yr. Month Yr. Month [�C ❑Credit rms & Conditions DISCOUNT lot responsible for damage beyond the curb,Ahe. 3.1.5%per month will be charged to accounts past due. 11 complaints shall be reported within 4 8 Zhours. 4.The purchaser agrees to pay all cost of collection. TOTAL -undersigned agree to all term and`co nditiorj5- tomer Signature Serviceman