HomeMy WebLinkAboutTitle V Inspection Report - 1895 SALEM STREET 5/30/2017 Commonwealth of Massachusetts
Title 5 Official Inspection Form
-- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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.:,, �• 1$95 Salem Street
Property Address
Paul and Lucille Roy
OwnerOwner's Name _...__...,._..,_.,_._-__.-- _..._ ...,..___._..._..._.,_-.,__.- .__..._...._
information is North Andover MA 01845 05-17-2017
required far every ___.._._,_--------.---. ___......._....� _ ._.. _.._.__,__._.,._,.._...................._--
page, City/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.
Important:When A. General Informationfilling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do notQ
use the return Benjamin C. Osgood, Jr.
ke Name of Inspector ( ,. _._......,...._
Y
none
r� Company Name
157 Bluff Street
Company Address
rerwn Salem NH 03079
City/Town State Zip Code
978-435-1324 870
Telephone Number License Number
B. Certification µ ---
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 Evaluation by the Local Approving Authority
t
05-24-17
Inspector's Sigfiature 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.
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ye'4 1895 Salem Street
Property Address
Paul and Lucille Ro
Owner Owner's Name
information is MA 01845 05-17-2017
required for every North Andover s
page Cityrrown State Zip Code Date of Inspection
i
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all of Section D
A) System Passes:
® l 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.
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 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.
❑ Y [] N ❑ ND (Explain below):
NIA
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t5ins•3113
I
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form Not for Voluntary Assessments
w,. 1895 Salem Street
Property Address
Paul and Lucille Roy
Owner Owner's Name
information is North Andover MA 01845 05-17-2017
required for every State Zip Code Date of Inspection
page Cityfrown
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B} System Conditionally Passes(cont.):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
NIA
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
F] obstruction is removed F1 E] N ❑ ND (Explain below):
NIA
9
B C} Further Evaluation is Required by the Board of Health:
u ❑ 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(i)(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
i.
15ins•3113 Title 5 Official inspection Farm:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Ro
Owner Owner's Name
information is
required for every North Andover MA 01845 05-17-2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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.
❑ 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 DFP 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.
3. Other:
d
D) System Failure Criteria Applicable to All Systems.
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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
E3 ® 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 '/z day flow
i Title 5 Official Inspection Form:Subsurface Sewage t7isposM system•Page 4 of 17
t5ins•3113
ii
Commonwealth of Massachusetts
Title 5 Official Inspecti®n Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Roy
Owner Owner's Warne
information isNorth Andover MA 01845 05-17-2017 _
required for every State Zip Code Date of Inspection
page. CitylTown
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year MOT 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.
El ® 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 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 DBP 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 falls. 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 Wealth 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
9, El ® 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-W IWPA) or a mapped Zone ll 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.
t5ins•3113 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 5 of 17
I'
Commonwealth of Massachusetts
u; Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Roy
Owner Owner's Mame
on is
required
for every North Andover MA 01845 05-17-2017
requir
page. CitylTawn 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?
F1 ® 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
El available note as NIA)
® ❑ 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)]
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): 550
3
u
t5ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 6 o€17
Commonwealth of Massachusetts
. Title 5 official Inspection Form
} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Ro
Owner Owner's Name
information is North Andover MA 01815 05-17-2097 i
required for every
page. City Town State Zip--code Date of inspection i
D. System Information
Description:
1,500 gallon se tic tank, and leach field
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? {Include laundry system inspection C] Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
House only used for 6 months during the summer
Sump pump? ❑ Yes ® No
current
Last date of occupancy: gate
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Crease trap present? ❑ Yes ❑ No j
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
3 t51fiS•3133 Title,5 Official lnspec€ion Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
w Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
„
1895 Salem Street
Property Address
s
Paul and Lucille Roy
Owner Owners Name
information is
required for every North Andover MA 01845 05-17-2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
6 years per BOH
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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)
❑ 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 IIA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
i
E t5ins-3113 Title 5 Ofclat Inspection Form:Substirface Sewage Disposal System•Page 8 of 17
t
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Ra f
Owner Owner's Name
information is North Andover MA 01845 05-17•-2017
required for every
page. cityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
House built in 1976. System is original
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
NIA
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipe Q1 �n basErrien
Septic Tank(locate on site plan):
6"
Depth below grade: feet
9
p
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
1,500 gallons
Dimensions:
2„
Sludge depth:
15ins•3113 'title 5 pfda$Inspection Form:Subsurface Sewage Disposal System•Page 9 or 17
'
Commonwealth of Massachusetts
Title 5 Official
Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1885Salem Street
Property Address
Paul and Lucille Ro
Owner Owner's Name
information Is1 -2O17
muuimdfor evem North ''
page. ..y'.~~. State Zip
Code Date of Inspection
D.-System Information (cont.)
Septic Tank(oont)
Distance from top of sludge to bottom nfoutlet tee or baffle --
3"
Scum thickness �
6"
Distance from top nfscum totop ofoutlet tee orbaffle
14"
Distance from bottom of scum to bottom of outlet tee or baffle
Measure stick
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid |eva|o as related tooutlet invert. evidence of leakage, etc.):
.Tank in good condition. Cross baffles intact. Recommend installation ofGCH 40 PVC tees.
_
Grease Trap(locate onsite p|an):
Depth below 0nade� fee
Material nfconstruction,
Floononate nneba> fiberglass El polyethylene Elother(exp|oin):
Dimensions: '
Scum thickness
Distance from top ofscum totop ofoutlet tee orbaffle
Distance from bottom ofscum tobottom ofoutlet tee orbaffle
Date Vflast pumping: Date
��som�o' —m�ow"n�=�o����om°�"n/��u/op�m'p"�1uu1,
mm"'xnu
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Roy
Owner Owner's Name
reformation is
required for every North Andover MA 01845 05-17-2017
page. Cityfr-ow n 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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site pian):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
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.):
B
*Attach copy of current pumping contract(required). is copy attached? ❑ Yes E] No
i
S Ons•3113 Title 5 Official Inspection Farm:Subswface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�., 1895 Salem Street
Property Address
Paul and Lucille Roy _
Owner Owner's Name
information is A
required for every North Andover MA 01845 05-17-2017
page, City/Town State Zip Code Date of inspection
D. System Information (cont,)
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.).-
Box
tc.):Box in good condition. Liquid levels normal no indication of leakage in or out or carryover
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.):
0
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I' [sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
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Subsurface Sewage Disposal SymtennForm -NotforVo|unba[yAanosomento
1895 Salem Street
Property Address
Paul andLciU Roy
Owner OwnaeaNuvm
information is 01845 05-17-2017
required for every North Andover —A
page. ~'v''~~^ State Zip Code Date of Inspection
D. System Information (cont.)
Type
[l leaching pits number:
Fl leaching chambers number:
Fl leaching galleries number:
Fl leaching trenches number, length:
1 field 20 x SO
leaching fields number, dimensions:
overflow cesspool number: --
El innovative/m|harnaUvasyabam
Txoe/nmmooftechnology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
etc.).-
Stone in leach field dry and clean.
No ponding, daTg soil, or breakout observed
!
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Oapth —tnpof|iqu|dtoinletinvod
Depth ofsolids layer
Depth ufscum layer
Dimensions ofcesspool
Materials of construction
Indication ofgroundwater Inflow El Yes Fl No �
�
16ins 3113 Title 5 official inspection Fonn:SubsLjrfaco Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
u p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Roy
Owner Owner's Name
information is
required for every North Andover _MA 01845 05-17-2017
(lase, city/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Officiai Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
i
Commonwealth of Massachusetts
Ile 5 Official Inspection Form
Subsurface Sewage Disposal System Form�Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Ro
Owner Owner's game
efn isreqafired or every
North Andover
MA 01845 05-17-2017
page. City/Town State Zip Code Date of inspection
s
D. System information (cont.)
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 thebuilding. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
P-W:�O'v 4
-4
4�
2 -TFl1UIt- 11 .5
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l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1896 Salem 2Vnaet
Property AdVmuo
Paul and Lucille Ro
Owner Owner's Name
information is
Andover MA O1845 O517-2O1
mqu|nodfor every North -----' --------
page- Cityrrown State zip Code Date mInspection
D. System Information (cont.)
Site Exam:
[�
Surface water
F7
Check cellar
�]
Shallow wells
31
Estimated depth bohigh ground water: feet
Please indicate|ndiomtwaU methods used to determine the high ground water elevation:
Obtained from system design plans on record
1978
If checked, date ------
' � Dote
C>boenxad site(abutting property/observation hole within 150 fasd of SAS)
�l
Checked with local Board ofHealth ' explain:
�l
Checked with local excavators, installers-(attach documentation)
E7 AooesnmdUQGS database-explain:
You must describe how you established the high ground water elevation:
Experience ofthis inspector|s that the E8HVVTinthis area |o30to40inches below grade. This
system was constructed in a low area that was filled and the bottom is only 2' below grade which
Before filing this Inspection Report, please see Report Completeness Checklist onnext page.
Commonwealth of Massachusetts
Q. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1895 Salem Street
Property Address
Paul and Lucille Roy
Owner Owner's Name
information is
required for every North Andover MA 01845 05-17-2017
page, cityrrown State Zip Code Date 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)completed
® System information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn an page 15 or attached in separate file
d t5ins-3113 Title 5 Official Inspection Foran;Subsufface Sewage Disposal System•Page 17 of 17
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