The URL can be used to link to this page

Home My WebLink AboutTitle V Inspection Report - 9 INGALLS STREET 3/28/2018 Commonwealth of Massachusetts IVED Title 5 Official Inspection Form RECE W Subsurface Sewage Disposal System Form Not for Voluntary Assessments [yl�1 [)OVER tjrjj�11-1 N4 9 INGALLS STREET Property Address DAVID DELANEY j Owner Owner's Name information is required for every NORTH ANDOVER MA 018.45 3/26/18 ——---- 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 filling out forms A. General Information on the computer, use only the tab 1 Inspector: key to move your cursor-do not JAMES H. CURRIER 11 use the return Name of Inspec key. tor ...................................... ........... TS SEPTIC & DRAIN .......... & Company Name � I 131 FOREST STREET -b"0-mp"a-n,y-Address enan MIDDLETON MA 01949 City/Town 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 16.340 of Title 6(310 CMR 15.000).The system: 0 Passes El Conditionally Passes E] Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/26/18 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 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. t5ins.cloc-rev.6116 TiUo 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts UNA ��o�0�� ^��N N��=�� U�0�� Title �� w�� m� Inspection Form Subsurface Sexxage ��isposa1SystwmmFmrmn -Notf0rVo|unteryA�m�e�noenbs 9 |NGALLGSTREET Property Address O/V|DQELANEY Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 ��018 page. State Zip Inspection B. Certification (cont.) Inspection Summary: Check A.B,C.DorE/always complete all ofSection D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303orin 310 CMR 15.3O4exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY. System�temn (��m�i��nmNyPa��' ' . . � F� One ormore system components agdescribed inthe "Conditional Pass"section need tobe replaced urrepaired. The system, upon completion ufthe replacement orrepair, aoapproved bv the Board mfHealth, will pass. Check the box for"vaa", °no" or"not determined" (Y. N. ND)for the following statements. |f"not dmbormined.^ 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 ifthe 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 |sless than 2Oyears old |s available. El Y F-1 N F-1 NO (Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 INGALLS STREET Property-Address DAVID DELANEY Owner Owner's Name information is NORTH ANDOVER MA 01845 3/26/18 required for every page. Cit-y/Town- State Zip Code Date of Inspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): F-1 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 El Y n N F] ND (Explain below): ❑ obstruction is removed 0 Y n N F1 ND (Explain below): ❑ distribution box is leveled or replaced n Y 0 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): F1 broken pipe(s) are replaced El Y n N El ND (Explain below): ❑ obstruction is removed [I Y n N El ND (Explain below): C) Further Evaluation is Required by the Board of Health: F-1 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: El Cesspool or privy is within 50 feet of a surface water F1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins.dor•rev.6116 Title 5 Official Inspection Form: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 9 INGALLS STREET party Address DAVID DELANEY —----- Owner 6 Name "— information is NORTH ANDOVER MA 01845 3/26/18 page. required for every City/ own State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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: El 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. F-1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, F 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 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 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 El 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 El E]. � Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow (5ins.doc-rev.6116 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 9 INGALLS STREET Property-—Address DAVID DELANEY Owner Owner's Name information is NORTH ANDOVER MA 01845 3/26/18 required for every ----------- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El N 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 El N tributary to a surface water supply. F-1 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. El M Any portion of a cesspool or privy is within 50 feet of a private water supply well, El ED 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.] El M 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 indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No El ❑ the system is within 400 feet of a surface drinking water supply El El the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area–IWPA) or a mapped Zone 11 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.doc rev.6116 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 INGALLS STREET ----------- Property Address DAVID DELANEY -------- Owner Owners Name information is NORTH ANDOVER MA 01845 3/26/18 required for 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 Z El Pumping information was provided by the owner, occupant, or Board of Health [1 z Were any of the system components pumped out in the previous two weeks? z F 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? Z EJ 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? * El Were all system components, excluding the SAS, located on site? * El 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? M F1 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: Z F-1 Existing information. For example, a plan at the Board of Health. 11 z 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: 3 Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 INGALLS STREET —------ Property Address DAVID DELANEY Owner owners Name I information is NORTH ANDOVER. — MA 01845 3/26/18 every required for eve page. State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? El Yes M 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)): WELL Detail: Sump pump? E Yes El No CURRENT Last date of occupancy: 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? El Yes El No Industrial waste holding tank present? F Yes El No Non-sanitary waste discharged to the Title 5 system? El Yes R No Water meter readings, if available: 15ins.doc rev.6116 Title 5 Official 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 9 INGALLS STREET Property Address DAVID DELANEY Owner Owner's Name information is NORTH ANDOVER MA 01845 3/26/18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: aiie-- Other(describe below): General Information Pumping Records: Source of information: LPD-2012 Was system pumped as part of the inspection? D Yes M 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 El Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) El 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins.doe-rev.8116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "4 9 INGALLS STREET Property Address DAVID DELANEY Owner _ ...._. _ . ..____ _._....... .....____. _._.........__. _.....__ __....._ _.......__ _ ..m.. Owner's Name information is NORTH ANDOVER MA 01845 3126118 required for every — . _...__-- _..... _._......_....— __�__.._ _., ------- page. _._ page, CftylTown p Code Date of Inspection . Mate Zi D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: SYSTEM INSTALLED 1975- NEW TANK INSTALLED 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 16" Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance fromrivate water supply well or suction line. 28 p feet Comments (on condition of joints, venting, evidence of leakage, etc.): PIPES IN GOOD CONDITION, NO SIGNS OF LEAKAGE. Septic Tank (locate on site plan): 10" 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 F] No 5'8"X 10'10"- 1500 GALLONS Dimensions: - _...._._._ _....._._.. 6" Sludge depth: _.__..._ __........ t5ins.doc•rev.6116 Title 5 Official Mspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 INGALLS STREET ............... Property Address DAVID DELANEY Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 3126/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 28" Distance from top of sludge to bottom of outlet tee or baffle 0-1 Scum thickness 81' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1711 How were dimensions determined? TAPE MEASURE & SLUDGE JUDGE 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, RUNNING AT PROPER LEVEL, INLET AND OUTLET TEES IN PLACE, IN GOOD CONDITION. OUTLET COVER WAS RAISED TO WITHIN 6" OF GRADE. ........... ------ Grease Trap (locate on site plan): Depth below grade: Material of construction: El concrete F1 metal F-1 fiberglass El polyethylene Fj 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: 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts -r Title 5 Official Inspection Farm p Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 INGALLS STREET Property Address DAVID DELANEY ` —..._..._. .._._. ....... _..... __._..—_.� ___--....._. ...__ _. __ _.........._..— Owner Owner's Name_ information is NORTH ANDOVER MA 01845 3/26/18 requiredfor every ..._. ..w..........—...... ...._..._ _...._.— _—......� —.Y....__ _..__ _,.... _.._..__ ..... __ page, Ctty/Tawn 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 plan): Depth below grade; ......._. ----......_ Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: __...._ __......-- __.._._.. Capacity: aiions _._..__ _.... ...__ 9 Flaw: .. -._ Design galtans pe..r�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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts =- y Title 5 Official Inspection Form 4 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W 9 INGALLS STREET Property Address DAVID DELANEY Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 3/26/18 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 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.): DBOX WAS LEVEL, NO SIGNS OF LEAKAGE, RUNNING AT PROPER LEVEL NO SIGNS OF SOLIDS CARRYOVER. BOX IS 13" BELOW GRADE, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or 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: 15ins.doc rev.6116 Title 6 Official Inspection Form:Subsurface Sewage disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 INGALLS STREET - Property Address DAVID DELANEY Owner gwners Name information is NORTH ANDOVER MA 01845 3/2611$ required for every _. _.. _ �._.._..._..._ ..— __.._. page D. System (nf01"f"natlOn (cont.) — State Zi Code pate of Inspection r - p _..... v Type: ❑ leaching pits number: ❑ leaching chambers number: -_.._................_ ❑ leaching galleries number: - - ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20`X40'WITH 4LINES ❑ 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, SOILS DRY, VEGETATION NORMAL. 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 f5ins.doe-rev.6/16 Title 5 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 9 INGALLS STREET Property Addire sis" DAVID DELANEY Owner Owner's Name Information is NORTH ANDOVER MA 01845 3/26/18 required for every —-- -- ................ . page. citFrr6wn-""-"" 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Officonal Inspection Form Subsurface tewage Disposal System Form-Not for Voluntary Assessments 9 INGALLS STREET Property Address DAVID DELANEY Owner owner's Name information is required for every NORTH ANDOVER MA 01845 3/26/18 page. City/Town State— �ICod6� Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two 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: FA hand-sketch in the area below El drawing attached separately Ln)an IC-a 64 V n�d t5ins•11110 ride 5 o1ricial Inspection Form:subsutipme sv?rsp Dispnol srztum Pap 15 of 15 Commonwealth of Massachusetts u 5 Title 5 official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 INGALLS STREET Property l ddres s DAVID DELANEY t7wnerC3wners Name _.— ___ ....._—.�... _... .. f information is required for every NORTH ANDOVER MA 01845 3126118 r _. ..__ .._._.._.. — .....__ .....,__._ -_._ ..... __ ... _....... .____ page. Cltyrrown State Zip Code Date of Inspection D. System Information (cant) Site Exam: Q Check Slope Surface water ® Check cellar ❑ Shallow wells 81 Estimated depth to high ground water: 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: GROUND WATER DETERMINED FROM ABUTTING PROPERTY STANDING WATER AND WATER IN SUMP HOLE IN BASEMENT FOUND TO BE 8' BELOW FINISH GRADE @ SEPTIC SYSTEM. i i i Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a` �P. 9 INGALLS STREET _..__.. . __........_ _...._ -- DAVID _...._ _.... - Property Address DAVID DELANEY Owner Owner's Name information is NORTH ANDOVER MA 01845 3126/18 required for every ............ ... _ .....�. ......_._.__... ..._...— —......_e .,,........, page. Cit yR[T own 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 i i i i i I t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pane 17 of 17