HomeMy WebLinkAboutTitle V Inspection Report - 1060 SALEM STREET 8/29/2017 Commonwealth of Massachusetts
Title 5 Official Inspect"on Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1060 SALEM STREET
Prope—rty-Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER .................... MA 01845 8/26/15
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
filling out forms A. General Information
on the computer, N E D
use only the tab 1. Inspector: rm
key to move your
cursor-do not JAMES H CURRIER 11 �[P 10
use the return Name of Inspector
key. X10 H ANDOVEAF'�
LIH L)LP/`J`(1WENY
J'S SEPTIC & DRAIN
Company Name
-131 FOREST ST
Company Address
MIDDLETON MA 01949
Cityrrown State Zip Code
978-774-6685 512327
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 16.000). The system:
M Passes r-1 Conditionally Passes Fain
FI Needs Further Evaluation by the Local Approving Authority
8/26/15
Inspector's Signature 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 s.,stern 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.
16ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1060 SALEM STREET
property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC. _
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01945 $126115
_
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E 1 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 ure
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):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17
Y Commonwealth of Massachusetts
y Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
y 1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC,
Owner Owner's Name
information dfor s NORTH ANDOVER MA 01845 8/26/15
required for every
page. City/Town State Zip Code Date of Inspection
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 (cant.):
❑ 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):
❑ 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):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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(9)(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 wetiand or a salt marsh
Wins•3113 Title 5 Official Inspection Form:Subsurface Sewage Msposal System-Page 3 of 17
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126115
page. CitylTown 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 60 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 DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other;
D) System f=ailure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® El clogged
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
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126115
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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
`�1'p� tributary to a surface water supply.
E] ❑ 1`, 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.
❑ ❑ 14 ' 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 forma
❑ ❑ C 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 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 indicatXtheye
" " or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is et of a surface drinking water supply
the system iset of a tributary to a surface drinking waver supply
❑
E] Area
system is located in a nitrogen sensitive area (interim Wellhead 1rotection
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.
l5ins•3143 Title 5 Official Inspection Form- �, A sewage oisposal system-Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'v 1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126115
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?
❑ ❑ �6Were as built plans of the system obtained and examined? (if they were not
1available 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): NA Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
(Sins•3/13 Title 5 Official Inspection Form:Subsurface sewage-Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
owner Owner's Name
information€s NORTH ANDOVER MA 01845 8126115
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ® 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))� 126.61 GPD
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: Dat
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:
t5ins-3113 Title 5 Officiai Inspection Form:Subsurface sewage Disposal system-Page 7 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
equired on Is for every
rNORTH ANDOVER MA 01845 8126115
required
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 616113 LPD
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):
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage❑}sposal System-?age 8 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1060 SALEM STREET
Property Address
SETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126115
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
UNKOWN
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2611
feet
Material of construction:
® cast iron ❑ 40 PVC ❑other(explain):
Distance from private water supply well or suction line: NA
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
16"
Depth below grade: 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: -
Sludge depth: NA
t5ins•3113 Title s omcia3 inspection Form:subsur€aca sewage Dis;osal System•Page 9 of 17
Commonwealth of Massachusetts
n a Title 5 Official Inspection Form
A s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1050 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126115
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
Scum thickness NA
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
LIQUID LEVEL IN TANK IS OVER FULL, TANK NEEDS PUMPING.
Grease Trap (locate on site an):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyeti-iylene ❑ 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
3 l5ins•3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
i
I
Commonwealth of Massachusetts
u : Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t
1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8128115
page, City/Town state Zip Code Gate 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 plan):
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.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Dispooal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC,
Owner Owner's{Name
information is
required for every NORTH ANDOVER MA 01845 8126115
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
COULD NOT LOCATE DUE TO SURCHARGED LEACH FIELD.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ""^ ❑ No*
Comments (note condition of pump chamber, condition of pumps and apourtenai ices, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site pian, excavation not required):
If SAS not located, explain why:
t5ins•3713 Title 5 Official Inspection Form:subsurrace Sewage oisposai system•Page 12 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7
s 1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126/15
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions;
NA
❑ 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.):
USED BAR IN FIELD, FOUND SYSTEM SURCHARGED AND IN HYDRAULIC FAILURE.
PREVIOUS PUMP REPORT STATED LEACH FIELD RUN BACK.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes [ No
t5ins-3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is NORTH ANDOVER MA 01846 8126115
required for every
page. City/Town State Zip Code Elate 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, conation of vegetation,
etc.):
t5ins•3113 TWO 5 Of dal Inspection Form:Subsurface Sewage Disposal system•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126115
page. City/Town State Zip Code hate 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 permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
9
l5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
k Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.' 1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 8126115
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shadow wells
Estimated depth to high ground water: NA
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 propertylobservation 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:
ESHGW NEEDS TO BE FOUND, WHEN NEW LEACH FIELD 1S INSTALLED.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•W 3 Tills 5 Official Inspection Form:subsurface Sewage maposal System•Page 160f 17
Commonwealth of Massachusetts
n Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1060 SALEM STREET
Property Address
BETTER HOMES OF BOSTON REALTY GROUP LLC.
Owner owner's Name
information is
required for every NORTH ANDOVER MA 01845 8128115
page. Cityfrown 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 on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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M18C.PEE A'MIN FEE 0,63 0/$ 7.92 11
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Date Reading Cade Consumption Posted Dane Variance �
0/6/2816 1488 a.AcNal 28 7/24/2015
302016 1139 aAetuai 22 4028015 6% i
121412014 1417 aActuel 18 1/1612016 -30'1 �
919J2014 1398 a Aolval 30 /0/1512014 t1%
$11112014 1368 &Actual 26 7/1812014 10%
317/2014 1342 aActual 2A 411,112014 1704
121512013 1316 a Actual 20 1/17/2014 -12%
818/2013 128E a Actual 23 1011012013 -2%
8/7/2013 1275 s Art" 24 7/24!2013 4%
121712012 1229 aAatual 21 118/2013 44%
91712012 1208 a Actuml 25 10/1512012 10%
9!612012 1183 0 Actual 21 711812012 2%
317!2012 1182 a Actual 21 4114/2012 0%
121612011 1141 o A*Wl 20 1117)2012 -28%
9/712011 1171 a Actual 29 1011312011 260!6
8!612011 1092 a Actual 24 7120/2011 13va
31x12011 1066 a Actual 10 41'V2011 30A
1216/2010 1040 aActual 19 11{212011 •21«�+
0/812010 1030 aActuel 26 *1612016 •19%
61412010 1004 aActual 31 71/6/2010 37%
313010 673 aActuai 21 411412010 4%
121717009 962 sActual 22 111212010 -130/6
9/412009 830 a Actudl 25 10118/2009 -610A
8/312009 905 a Actual 47 772412000 1131%
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