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Home My WebLink AboutTitle V Inspection Report - 2211 TURNPIKE STREET 6/28/2018 Commonwealth of Massachusetts y. Title 5 Official Inspection Form Real Subsurface Sewage Disposal System Form Not for Voluntary Assessments I- 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS Owner Owner's Name information is required for every NORTH ANDOVER MA 01845. 6/6/18 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: .............. Important:When A. General Information filling out forms 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 Inspector ..........- key. J'S SEPTIC & DRAIN Company Name 131 FOREST STREET Company Address MIDDLETONMA 01949 ------------------- City/Town State Zip Code 978-774-6685 S12327 Telephone i'-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 5(310 CMR 15.000). The system: 0 Passes F-1 Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority X/ 6/6/18 ............... ll� edors Sign 4t6re 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. t5ms.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts -- r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS Owner Owners Name information is required for every NORTH ANDOVER MA 01845 616118 ..........�_ _.. _........ _.. ....... _ ............._— page. Cftyrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY, WE REPLACED DBOX ON 6/13/18. 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SevxmgeDisposmASysbemnFormn - NotforVo|unbaryAsoeenmmnts 2211TURNPIKE STREET Property Address ESTATE {}FRECARDODEJESUG Owner Owne/vNome ------ information is required for every NORTH ANDOVER MAA 01845 6/6/18 _ page. °"'''~``^ State —' Code Date of Inspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational. System will pass with Board ofHealth 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 ofBoard ofHem|th): �l broken pipe(s) are replaced 0 Y N [l ND (Explain be|ow): � obstruction is removed E] Y N ND (Explain below): F] distribution box isleveled mreplaced Y n N F-1 N0 (Explain below): El 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 ofthe Board ofHma|ih): broken pipe(s) are replaced Fl Y Fl N F-1 ND (Explain be|ow): � obstruction is removed El Y 0 N Q NO (Explain below): C) Further Evaluation |mRequired bvthe Board ofHealth: Fl Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public hea\th, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.3O3(1)(b)that the system |snot functioning knwmanner which will protect public health, safety and the ennimmmmnew± �l Cesspool orprivy iowithin 5Ofeet ofasurface water �� Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts ............. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/6/18 page. dit—y/Town—" State Zip Cod.e 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: F-1 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. R The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. F-1 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 F-1 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded 0 M or clogged SAS or cesspool 0 El Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc-rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 17 � � Commonwealth of Massachusetts ----------- Title �'��N�� `��*=��N 0�� U�N�M� � @�� =�� N�� Inspection 0—��mwm � Subsurface Sem/age DisposaCSystenmFornm - NotforVo|untaryAsoesomentn 2211TURNPIKE STREET 0r—op,erty Address ESTATE {}FF(ECAR[]DDEJESUG Owner Owner's Name information is NORTH ANDOVER MA 01845 6/6/18wquimd�rmm� page. S�5e -- Zip Code Date ofInspection B. Certification (cont.) Yeo No Fl �� Required pumping more than 4times inthe last year NOT due hoclogged nr obstructed pipe(s). Number of times pumped: El 0 Any portion ofthe SAS, cesspool orprivy iebelow high ground water elevation. �� [l /\nypodionofcesspool nrprivy invvithin1O0feet ofasu�aoewater supply or �� tributary toosurface water supply. El El Any portion ofmcesspool urprivy iawithin oZone 1 ofapublic well. Fl El 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 lfthe well water analysis, performed mtaDEP certified laboratory,for fecal coliform, bacteria indicates absent and the presence mfammonia nitrogen and nitrate nitrogen isequal tuorless than ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain ofcustody must be attached tothis form.] � El �� Thaeyatonnisaueespoo| aervingmfooi|ityvvi(hmd*eiQnDowof2OOOgpd- �� 10.000g9d. � El �� The system | have determined that one ormore ofthe above failure �� criteria exist modescribed in 310 CK8Fl 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary tocorrect the failure. E) Large Systems: To be considered m large oysb*nn the system must serve a facility with a design flow of 1¢,$00 gpd tm15'RUQgpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions inSection D. Yen No El Fl the system iswithin 4OOfeet Vfasurface drinking water supply El El the system is within 200 feet ofatributary to aeudace drinking water supply Fl �l the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—|VVPA) oramapped Zone |1ofmpublic 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 fai|ed. The owner oroperator ofany 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 ofthe Department. '*u^'mu'rev.swv Title 5Official Inspection Form:Subsurface Sewage Disposal System^Page uofo Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS Owner Owner's---Name information is NORTHANDOVER MA 01845 6/6/18 required for every page. 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 E n Pumping information was provided by the owner, occupant, or Board of Health El E 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 El E this inspection? E El Were as built plans of the system obtained and examined? (If they were not available note as N/A) E El Was the facility or dwelling inspected for signs of sewage back up? M El 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): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 450 GPD t5ins,doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2211 TURNPIKE STREET Property Aodress ESTATE OF RECARDO DEJESUS . ....... Owner Owner's Name information is NORTH ANDOVERMA 01845 6/6/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: .......... Number of current residents: 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? El Yes M No Water meter readings, if available(last 2 years usage (gpd)): WELL Detail: Sump pump? El Yes E No Last date of occupancy: CURRENT Date Commerciallindustrial 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? El Yes El No Non-sanitary waste discharged to the Title 5 system? ❑ Yes n No Water meter readings, if available: t5ins.cloc 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 2211TURNPIKE STREET ESTATE (}FRECARO{} DEJEGUS Owner Owner's Name information is NORTH K�AO1845 0/8/18 required� �� 4 ,� page. ��-- ZipCode Date of Inspection D~ System Information /cont.\ Last date ofuocupenoyuae: Date Other(describe bo|ovv>: General Information Pumping Records: Source ofinformation: NONEON F|LE Was system pumped aspart ofthe inspection? Yes No 1500 |[yes, volume pumped: gallons TRUCK GAUGE How was quantity pumped determined? MAINTENANCE & DBD)( REPLACEMENT Reason for pumping: — ---- TvpemfSnstemm: M Septic tank, distribution box, soil absorption system El Single cesspool �l Overflow cesspool Privy El Sharedsystem (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 ofthe |A\system bysystem operator under contract / F� Tight tank. Attach acopy ofthe DEP approval. [l Other(describe): Commonwealth of Massachusetts 'Title 5 Official Inspection Foran _ - n Subsurface Sewage Disposal System Farm Not for Voluntary Assessments w . � 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS Owner Owner's Name information is NORTH ANDOVER MA 01845 6/6/18 required for every ... .__._. .._.___.. _........ _...,.,__. �._...,.... ..._ _.. _...._. .._ _ _. .. page dity/Tonrn State Zip Code Date of Inspection D. System Information (cant.) Approximate age of all components, date installed (if known) and source of information: AS BUILT DATED 12/3/85 D BOX REPLACED 6/13/18 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site.plan): 12" Depth below grade: feet_.....__.. Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): _ Distance from private water supply well or suction line: 4' Comments (on condition of joints, venting, evidence of leakage, etc.): LOOKS TO BE IN GOOD CONDIITON, NO EVIDENCE OF LEAKAGE. Septic Tank (locate on site plan): 6" Depth below grade: feet- _..__. ..... Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Y ears .._.. ....____ __..__. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 GALLON - 10'6"X5'6" Dimensions: -- _...........__ _.— Sludge depth: 4' I t5ins.doc•rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m - Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 2211 TURNPIKE STREET ._.. _._.__. __ . .......__ Property Address ESTATE OF RECARDO DEJESUS Owner __....... .. _ __. ....._.__.. __ _...... .._..._. .�..._ _.._...___ _... ._.____.. Owner's Name information ie _. _ required for every NORTH ANDOVER MA 01845 616118 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cant.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness _.....,,, _-._...._............. 811 Distance from top of scum to top of outlet tee or baffle — -_----------- _ _ .... Distance from bottom of scum to bottom of outlet tee or baffle 14' How were dimensions determined? 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 WAS PUMPED AS PART OF REPAIR, INLET AND OUTLET BAFFLES IN PLACE, OUTLET IS A PVC TEE. LIQUID LEVEL CORRECT. Grease Trap (locate on site plan): Depth below grade: feet .. _. ..._.._.. Material of construction: El 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: i t5lns.doe•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I <r Commonwealth of Massachusetts M = .mm w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2211 TURNPIKE STREET 'Property Address ESTATEOF RECARDO DEJESUS Owner Owner's Name information is NORTH MA 01845 6/6/18 required for every page. city/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete El metal ❑ fiberglass ❑ polyethylene F1 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: El Yes El No Alarm level: —----- Alarm in working order: F1 Yes [I No Date of last pumping: 'l:5We—-- - ---- ---- Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? F1 Yes El No t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2211 TURNPIKE STREET Property Address ESTATE ropertyAddiessESTATE OF RECARDO DEJESUS Owner Owner's Name information is NORTH ANDOVERMA 01845 6/6/18 required for every page. b-ifirT—Own —St a t-e— Z—ip C'o-d e 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.): DBOX WAS REPLACED ON 6/13118, BOX IS 4" 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: t5ins.doc•rev.6116 Title 5 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 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 .......... page. aiirt-o"Wri State Zip Code Date of Inspection D. System Information (cont.) Type: F-1 leaching pits number: ----------- E] leaching chambers number: n leaching galleries number: 0 leaching trenches number, length: M leaching fields number, dimensions: 1) 20'X 6.01' F-1 overflow cesspool number: El 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.): SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL. USED BAR TO PROBE FIELD AND FOUND TO BE DRY. 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 El Yes F-1 No t5ins.doc,-rev.6116 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 2211 TURNPIKE STREET Property Address ESTATE OFRECARDO DEJESUS Owner Owner's Name information is required for every NORTH ANDOVER 01845 page. Clttyitown-" 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 ..........Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts = = Title 5 Official Inspection Farm - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS OwnOwner _.e_r's..._._._.Na_me _._.............. ___ _ _ _ _..... information is NORTH ANDOVER MA 01845 6/6/18 required for every .............. __......... —_. .......__ _......, _ ._ _...........,._ page. City/Town State Zip Code 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: ❑ hand-sketch in the area below ® drawing attached separately t5lns.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 2211 TURNPIKE STREET Property Address dd r ass ESTATE OF RECARDO DEJESUS Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/6/1,8 ............. page. dit-y/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: M Check Slope R Surface water Z Check cellar ❑ Shallow wells 2.5 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record /11/85 If checked, date of design plan reviewed: 9Date —-------- —----- --- ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: El Checked with local excavators, installers - (attach documentation) F1 Accessed USGS database -explain: You must describe how you established the high ground water elevation: TEST PIT DATA ON FILE WITH B.O.H., TEST PITS PERFORMED 4/24/85. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins,doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2211 TURNPIKE STREET Property Address ESTATE OF RECARDO DEJESUS ---------- ............. Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/6/18 page. City1rown State Zip Code Date of Inspection E. Report Completeness Checklist 0 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 Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins.doc-rev.6116 ritle 5 Official inspection Form:Subsurface Sewage Disposal system-Page 17 of 17 11115 IV La hr)'f�.rLi r•-�t7 a� � ��,�, \ .F.-"!��.s� � /"" l*n�/`�•^w �(�4./ ,,.,.._./ I .. i -e 7 111 kF L- 0 74 Z,o r tr h c� .....,.....y-.r.,..,..+.1r.»,r.v.n+4r•rr.a,+a.Yi. vi ...rr:-.:rr v,r u�ru,.w, --...-,.rn.ay....ner�x .rLv.n.i!.r--.....evn.:'..rn..,.,,..........w_,,.r..i.i..,.,,.rr._.o-.0-,..r..-,_..w.w.�....., v-w..r..-..n.,«.r.«..w..._.__-,._.�.—�.-+—w_-_+...�