HomeMy WebLinkAboutMiscellaneous - 1253 SALEM STREET 4/30/2018 (3) J
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Title 5 official Inspection For i
° Not for Voluntary Assessments SEP - 7 2005
M Subsurface Sewage Disposal System Form TOWN OF NORTH ANDOVER
H''Al H DFIAR11-1ri=NT i
Inspection results must be submitted on this form or on the official Title 5nspecion Form 7a
6!1512000.Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the
computer,use 12S3 SA}(JA- STQk=T
only the tab key Property Address
to move your 6D74 I li 7f ZSCI -'
cursor-do not
use the return Owner's Name
key. 1 zS 3 51)-1 c n
Owner's Address
m r�o►Zflt A►yQOVt-fL" 1M A-
CityRownSta Zip Code
Date of Inspection_ lU rjU 5T 13, Zb
Date
2. Inspector.
- -ICI
Name of Inspector
Company Name
Z1 cAm 6 Z0g 5TUtTv- 5uITif- IUCo
Company Address
Cityrrown State Zip Code
-)&- -- qOq
Telephone Number
Certification Statement:
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:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Ne7 oer �Iutat' nnheoval Approving Auth rity
zu4uSr 13, '200S
Inspector's Signature Date
The system inspector sh submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 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.
t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
P �rty Address
roXroo it-} ,,IDo,c2
Cityrrown Stat Zip Code
eg-i)4 4 ,—zs cis au�u ST' ►3, wj s
Owner's Name Date of Inspection
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.
"-mments:
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 exfiltrabon 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:
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
I Z53 SA{- 'XR6-t7-
Pro rtyAddress,,ll
Cilyrrown State Zip Code
60ITt+ 41 i ZSCAS UCjUST 13, Zoos
Owners Name Date of Inspection
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
❑ obstruction is removed
❑ 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
t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
° Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
P,r9perty Addressl _
Cityrrown Sta a Zip Code
61-1M �I�TZsorF� �v�u s�r 13� Zoe
Owners Name Date of Inspection
C) Further Evaluation is Required by the Board of Health(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 DEP certified laboratory,for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility 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.
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
Pr�op�rty Address�ll
I�G
GTR I � wog-.
Cityrrown Stat ZipCode
t�tT ZSu / Uciu ST 13,Zooms
Owner's Name Date of inspection
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
❑ H Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
MO--D�boy,❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or cogged 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 clow%or v
obstructed pipe(s). Number of times pumped: 1;'U+ t' Ps'm =Y► zoo
RG��cPr2`VAivuTiNWcu t�.
❑ 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.
❑ R Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ [g 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 coliform bacteria and volatile organic compounds
Indicates that the well is free from pollution from that facility 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.]
Yes No
❑ ® 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.
t5insp.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 5 of 16
Commonwealth of Massachusetts
Title 5 official inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
1253 5A-n
Property Addre s
t4ot,4 rA
City/TownZip Code
S e
Owner's Name Date of Inspection
�l 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 efther'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
t5insp.doc•11/2004 Title 5 Official inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
Iz53 54-kery)
Pro rty Addre _
Cityrrown Sta Zip Code
CD1-N > I T ZS Q+6- ST 13, 2-0 0 S
Owner's Name Date of Inspection
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, occ ,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
DI ❑ 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 th`gg systerrp�t obtained and examined?(If they were not
available note as WA) `"O-4C A,JAItAbtE.
❑ Was the facility or dwelling inspected for signs of sewage back up?
9 ❑ 'JVas the site inspected for signs of breakout?
N ❑ Were all system components,excluding the SAS, located on site?
N ❑ 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?
to ❑ 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. Z �Co
❑ 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(3)(b)]
t5insp.doc•11!2004 Title 5 Official Inspection Form;Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
IZS3 Spf1 S G —
PTZ
res 11-� MpOyb�Z,
City/rownStat Zip Code
Owners Name Date of Inspection '
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: Z
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? CQ lJ6C r6D� �`1 i 0� 71t—LD- IM Yes ❑ No
Seasonal use? ❑ Yes ® No
We5 met r readings, if available(last 2 years usage( ));SI M GC +�I wu�
311Slos 1-1-l(q-sZ. rpCA90(9oa. gQjQrn . -�.D 10 5.
Sump pump? ❑ Yes ® No
Last date of occupancy: Q CCUPI to
Commercial/Industrial Flow Conditions: n ^^
Type of Establishment:
Design flow(based on 310 CMR 15.203); canons per day tgpd>
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):
t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
• P
404- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
7tP party Addre
RnJpoy��ZA-
CRY/Town State Zip Code
lZl'n AUCUS7 i3,Zo�5
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information:
OW�LIz.
Was system pumped as part of the inspection? IS Yes ❑ No
If yes,volume pumped: 1000
gallons
How was quantity pumped determined? M-:�SQIRIZD C0 Zia -
Reason for pumping: 41K I 0 p�►� V ULVJ�vim_
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/Altemative 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):
Z �2Gc�ST Com►--�CRc"� Gi2CUL�tZ �1�_�5c""���ti; �� �t1 Dc"i f�ll5)
Approximate age of all components,date installed(if known)and source of information:
It�ST&LU-D I 1914. FQk)T OWt.-k L
Were sewage odors detected when arriving at the site? ❑ Yes (g No
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
lugTitle, 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
-T`' 9£ TWOD' C. System Information (cont)
ce>Oc. IZS3 '5pmt
GC Pr pertyAdd s
I.�.tpov�lZ IYI�- 018y�
F CityrrownStat Zip Code
eont_ �Ln-zsc�a� ��o i3, Zoos
ZJ CJ.0-A U Owner's Name Date of Inspection
OUT q
7 Building Sewer(locate on site pian):
Z- rff+
( n1j Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain):
+Z5 Fes'
Distance from private water supply well or suction line: feet
Coments(on condition of joints,venting, evidence of leakage, etc.):
1�' C.;,cov�,Z N.C� (.�r�'AC,� o�Z �,gCK:U l t•� I-�c�usy.
1215E IL Septic Tank(locate on site plan): r 1+
Depth below grade:
13 J/Zr' feet
Material of construction:
ZZnconcrete Elmetal E]fiberglass ❑ polyethylene ❑other(explain)
-S
&Lc' Sw,�1) cc.R
i�1Zrr f9+� If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of El Yes E] No
certificate)
Csi r.�Gl 'l
Dimensions: Uti1K�
Sludge depth:
"► Distance from top of sludge to bottom o baffle 33-3S
Scum thickness i'�U
2�nIC.1�A i i5 4S11 +
SU u,�� Distance from top of scum to top of�baffle
(WAT x LC-V rt)
56Cu 2,E 1679 IAA)LDistance from bottom of scum to bottom of baffle
How were dimensions determined? T41P: ME�61J 4?z-
t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont)
Z?4yA11res4400'j6j
Cityrrown state
Zap Code
ZD)71-� �GTzso U;Q5r )5 Zoos
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as relatgd to outlet invert, evidence of leakage etc):
ZNl1v"� SI�� I u�5131�'_ wi�r�-I � �sI,1��y11' tilo 5�G�5 dF c��SA��
RNA K c2AcKS aPL ';%AYPAZ u Qui D l�1 CLS R' c7.ITXr 1,4\jkaL►. cm c-
3AP�,� I s SOU v D E' SECUQF.
Grease Trap(locate on site plan):�'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:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain):
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Inforfnation (cont.)
I zs 3 Sift t S vc-'
Prpperty Address
City/Town z Code
G-01-N ►�I-rzsc�—' Zte y��ST �3�ZOUS
Owners Name Date of Inspection
Tight or Holding Tank(cont.)
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.):
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.):
Pump Chamber(locate on site plan): W�)
Pumps in working order. ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
r Subsurface Sewage Disposal System Form
C. System Information (cont.)
Ptoperty Add re
r�W 1 .1Doy��t Xfi oto
City/Town Ste Zip Code
(b1)4 �t'f2SCfl�' ST
1�j, ZowD
Owner's Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
ACR IM raj t�--17 _ CSS 3�^L(x,J
L'emoq i�4 0 1'I-13 L CXATcSD ►3`j I IGS -3 4-LL
4"
1�1�6T
leaching pits number. Z
r_
,� ❑ leaching chambers number:
�a_ Ios'! ❑ leaching galleries number.
❑ leaching trenches number, length:
f. -� ❑ leaching fields number,dimensions:
LC. t I
❑ overflow cesspool number:
- ❑,.. innovative/aftemative system
Type/name of technology:
u .tts„
1�'
H�
z" k nts(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.).
A LoA6) 5Ak-AD ' CASS M 151Gris o�- P.-C924LL)c FAIIJ RC
I -N6- f4005 d� I -f1J� �►-h-1-1h 1 D�2 svl�- Cts►-brTIOAJ 5- �A
Ca��OITI nit S_ (.AW IS 12v�,Ut�Bt L OaY,
'� oTc•- SS
(E�+CNII r. "PIT' 15 el(y)�-m �3 U RU 10 ueu E-\
toll 5TQ`0�1 Or
t5insp.doc•11/2004 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 13 of 16
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
�-�-
d`Z. �-�
Cdyrrown J3MAI- 2
1171 6�I IT�G�� sta , ?SSU j zip rode
UG�S
Owners Name of Inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): r�A
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
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.):
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Ins ec#ion Form
p
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4
C. System Information (cont.)
1273 s s-r2s '
P operty'T�U�z
Ci y/TownS
GSD IT14 n�1TZ,50" i� p Code
OC U57'' /3 WOS
Owners Name Date of Inspection (.v
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.
I E-5
z
rr�3���► STLVq E; f11a1?Jr�1)z
CD ?t
W)c c,48u r
18 1W
I
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mcchlA 1tSv� (A W
ze►..I�tc,lnl�s�y__ � � 11
7D) X U
CCD
ro
a
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
I,„�; Page 15 of 16
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iJ 71�� 06kA 'PIk WIC$ 7nTL� WTf� I� C��i7� .� N�`:. W�It1Z(Z�i S
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Commonwealth of Massachusetts
BOOM Title 5 Official Inspection Form
Not for Voluntary Assessments _
Subsurface Sewage Disposal System Form
C. System Information (cont.)
lz573 � '��CST-
P party Add
1:74 ` 4couzN
cRyrrown ^ Sta Zi Code
y�Dl� 01TZSGI4 ?�y5
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water I Oo. I-
Check cellar 1712 �vn1Q �(1'1(� OIvV6� Ce11.��171U1.7 't;Ul��)k� s, 2
91 •� �tAOa--( t�6�L),� c6olj --m W
Shallow wells
Estimated depth to ground water - FTr
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design pian reviewed:
Date
Observed site(abutting properly/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
SQI L 7tT'-)Q9 off. WSlrt AR- A� 4-S , T lTL S I►�� �,, � > _
• ❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
51TG LJKK AROUP0 JPPUR, � �' �I�G�I r3v vop, U1Slwo &It) OF
2c;coq)S Too, 4v1r'IA Oa I'U5 C51 IpFo..*IZga = -I.;F`'-M +=•5,N,c.,).T�
I
ITLrr S I>45eC-cTTL)v4 �
5sumi0q �`AI►�, '�� of 3�i' �xls�n S G2Af��r wi�a AKS AR�vk_,
G►2uvt,�) A i1�T ceAG,41 .15 ?r,3•q,74D rr is
COQDLg4i GZ IS A� 20. P�' 6EWt.3 -NE- 515
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
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