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HomeMy WebLinkAboutPass - Title V Inspection Report - 46 WOODBERRY LANE 11/29/2023 rnonweafttl of Massachusefts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �roporty Address" O er a � ro information is rer{atutt tc every .. ...__._. ._._.......C...... _ Pa go. QtytTowrwn State Zip Code Date or Inspecton Inspection results mint be submitted on Oft form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. filling Important: rn A. Inspector Information �Ilalttwg out Corms on the computer, use only the tab .:. R. .... ' . ' _ ........ --- key to move your Nance of V or cttsor-do not d use the return `3a. ....... ..�.�.° _.. . . .. _. _ . rom rry key. _.... me rwa r C rota essM _ t Gityffowvn .. state Zip Code Te Nwttrt License Number B. Certification I certify that: l am a DIwP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.00 ); 1 have personally inspected the sewage disposal system at the property address listed above-,the information reported below is true„ accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the Proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. basses 2. Conditionally Passes 3. Q Needs Further Evaluation by the Local Approving Authority 4. El Fails Ins tor'sSig-nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or I EP")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 thie report to the appropriate regional office of the DER The original form should be sent to the system owner and copies sent to the buyer„if applicable, and the approving authority. Please note:This report only describes conditions at the time of Inspection and under the conditions of use art that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. t&nsp rtr M rev,Tr2fiM 18 TWO 5 OWWA h4MANI t'ea M&AWASUM SWAQP rASP=d SYMM"-PSge 1 rat 18 Commonwealth of Massachusetts � - Title 5 Off clo l Inspection Form ,n a� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address . Owner hers Name y informatpon is _. .... required for every . + . . .. page, Cat fy sown State Zip Code Date of Inspection C. Inspection ction Summary Inspection Summary- Complete 1,2„ 3„or 5 and all of 4 and 6. 1) 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:. _._ ---- p 2) System Conditionally Passes: El 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 " he Board of Health„ will pass. Checkw'#W box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined;°"",please explain. The septic tank is and over 20 years old"`or the septic hank(whether metal or not)Is structurally unsound,exhiibits substd' ° infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank""aced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection 6f at sVructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 26lars old is available. ❑ Y ❑ N ❑ ND(Explain below): tfAnspr.ctlm•rev.7126J" 1 B TWe 5 M.W trmpecAon F= ;Substsface SewaW Dorx -Flage 2 of M Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface age Disposal System Form Not for Voluntary Assessments g w s + d t _.. ........ Property Address NamOwner information is 4 'T required for every _..-..... _ ,, ._........... page. City/Town State Z Caxie Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Fusses (cant.): ❑ Pump Ch m'ber pumps/alarms s not operational.System will pass with Board of Health approval if pumps/alarm�',pre repaired. ® Observation of sewage�ackupor break out or high static water level in the distribution box due to broken or obstructedor due to a broken,settled or uneven distribution box.System will pass inspection if(with N I of Board of Health): ❑ broken pipe(s)are reply ® Y ❑ NEIPIG(Explain below): Q obstruction is removed ❑ Y ® N Q PIG(Explain below): ❑ distribution box is leveled or replad ❑ Y ❑ N ❑ ND(Main below): The system rewired 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 F] Y ❑ N F1 ND(Explain below)- El obstruction is removed ❑ Y E] N ❑ ND(Explain below): 3) Further Evaluation Is Required by the ward ci-"psalth: El Conditions exist which require further evaluation by Board of Health in order to determine if the system is failing to protect public health, safety or the nvironment. a. System will pass unless Board of Health determines I ccordance with 310 CMR 15*303(1)(b)that the system Is not functioning In a manner hick will protect public health, safety and the environment: t5#narr.aloc*rear.7A2ta 018 Mile 5 Offidal ktapeefion Farm:Subsurface Sewage Disposal Systern*Page 3 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments r PnVerty Adders Owrw inforrrmbon is required for INn � a ptytt"ow n state Zip of trws ..I.w........w ..._.__ __...—......�......__......_..._._____._._ _._..w__.. _.. ___..__ _M__....._..w_._.__.w_.__..._ . ._ _ _m....,...._ _._ .._..._ _... Ins ection Summary (cone.) 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 b. System wiil'fail unless the Board of Health(and Public Water Supplier, if awry) determines r tern is functioning in a mariner that protects the public health, safety and environment (j The system has a septic tanarld soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or"Mary to a surface water supply. Q The system haws a septic tank and SA d the SAS is within a done 1 of a public writer supply. El The system has a septic tank and SAS and the is within 50 feet of a private water supply well. El The system has a septic tang and SAS and the SAS is less n 7 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 CDEP 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 c. Other- -............ ___....._ 4) 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 Overioaded 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 t5Ov a,d(x raw.M61MIA Tl e 5 Off OffwW 1r4gxw )n Form Subanfam S~4W D*x"SysWm»Page 4 of 18 Commonwealth of Massachusetts _.: Title 5 Official Inspection Form ` Subsurface Sewage er l System am Form- heat for Voluntary Assessments - --- �V` Property Address Owner s Name inform 1 �ntorrrxaturawi is , .V, � ,,, .... reauared t every page. Cityrrown swe Zip� Date of Inspection . C..._.._4 .._...w,._..__.., __ ___..............w. __ .,............._ __ _........ .._._ Inspection Summary (cant.) 4) System Failure Criteria Applicable to All Systems. (coot.) Yes No Static liquid level in the distribution boat above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in pool is less than 5""below invert or available volume is less than '/2 day flow [ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). plumber of times pumped: © Any portion of the SAS, cesspool or privy is below high ground waster elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ° tributary to a surface wager supply. E] Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. [l 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 DP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia n en and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system falls. 1 have determined that one or more of the above failure criteria exist as d bed 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. 5) 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 For lar e ysterms,you must indicate either"eyes"or"no"to each of the following, in addition to the questions in"Seeborl„C.4. Yes No M 1:1 the system is within eet of a surface drinking water supply El ❑ the system is within 200 feet of alllftry to a surface drinking water supply the system is located in a nitrogen sensitivi area (interim Wellhead Protection El Area_IWPA)or a map Zone 11 of a public water supply well VAmp,doc.rev.?P2Bd"X18 Taft 5 Offlovr ImVedkxi q"=rram Subsurfam SewAga •Page 5 of 18 Commonwealth of Massachuseft Title 5 Officulal Inspection Form Subsurface Sewerage Disposal System Form-Not for Voluntary Assessments k�119 w'c.gat, Property Address �« OwnerOW information is w required for every _..._._.. _.. t page. C Ayrrown state Zip Code Date of tnspoctkm C . Inspection Summary (coat.) If you have answered"yes'to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shalt upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must Indicate "yes"or"no"for each of the following for a#inspections: Yes No El 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? E] 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 inspecfion? 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? `, El Was the site inspected for signs of break out? EJ 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? E] 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: Q Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Fart C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] V*mx.ar •ray.7060018 'rya 5 OffidM Marmw0m Fo m:FAsbsurftm»' •Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments Nopertyr Address Owner Ow s Name ... t ins isrequired for every page atyPfow State �r Date I r1 mm._TM........._....__.____ _.._ _...._rv._. _._.._.. ....w ____.w____. _..w._.w.. _.. _ ._w___. _. .._...._. ..__M.__..._.w__._._..___.... D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): w ..... Number o bedrooms (actual): DESIGN flow based on 310 CRMR 15.203(for example: 110 gpd x of ems): Description: Number of current residents: Does residence have a garbage grinder? E] Yes No Does residence have a water treatment unit? Yes PQ No If yes,discharges to: _.. ... 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)): Detail: Sump pump? F] Yes No C, Lest date of occupancy t5OWAoc.rev'..MfiMlS TMe 5 C966M ko4wac*)n R'w`Rwd': G Systwn•.Page 7 of 18 Commonwealth of Massachusetts Subsurface Sewage Disposal System dorm-Not for Voluntary Assessments R Arop----..... _..._.. f w. _....... _.. Pfopf�rty Address ! �� .^, . .............. Owner information is _ _._ ./e _ _ _.. ..... ....... ... ........ ..... ..._..... __ _...._. required for every _._.______�._....._..w__ __�___... A..•. page Gtyf�cwwrt state Zap Cade gate of Inspection __...._m ___._.. _......___..__._. _____ D. System Information (cont.) 2. CommercialAndustrial blow Conditions: Type of Es lishment: __...... _ __ _...._._ Design flow(bas on 310 CMR 15. : i�allons....Per Y(p ) Basis of design flow(s persons/sq.ft.,etc.): _ .. _....... _..._._.__._. _..... Grease trap present? [l "yes C] No Water treatment unit present?' n Yes El No If yes,discharges to: __._. _„ . _...__. Industrial waste holding tank present? ® Yes n No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: Last date of occupancy/use: _ __ ...._..._ _... ....._. ......__..___ ._ .. gate Other(describe below): _. . - - -------- _.. __ __ ..._ CA 3. Pumping Records: � � ����� ��� e� ��. � "' �w Source of information: Was system pumped as part of the inspection? Yes No If yes,volume pumped: _. __.._. _ .__ _............. .._. How was quantity pumped determined? —......______ _........ Reason for pumping: ........ ......_. .._...... . _.... .. ..._._..____.___ _.__...... t5hwsp.doc•rev.712CM18 Title 5 Offida Form:Subsurface Sevrave DksposWS e 8 of 18 Commonwealth of Massachusetts Tie , Official Inspection Form w subsurface Sewage Disposal system Farm Not for Voluntary Assessments /p c, a.rt Property Address - Owner Own e es Nam information irequired for s _ � .. . _ ...... .. w... . .... _._ / _...._ page. City/TownY __._. State. ,Zip Code Date of Inspection D. System Information (cant.) 4. Type of system: Septic tank, distribution hex,sail absorption system [] Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes Cn �if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance con (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): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes K No 5. Building newer(locate on site plan): Depth below grade: — - feet Material of construction: 04,east iron El 40 PVC ❑other(explain): Distance from private water supply well or suction line: fee /Al Comments(on condition of joints,venting,evidence of leakage, etc.): t5hisp.doc•rev.7/26M18 Thfa 5 0fficW kwspeebw Fam Subsurface •Pap 9 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,(I Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments r" If fi l r Frown ty d dress Owner 7� required for ever)/ zy C, ..._ ___ _. .,. .. ... ....... page- CitylTown state Zip Code Date of Inspecflon D. System Information (cant.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete [] metal fiberglass [ polyethylene El other(explain) If tank is metal, list age: ars Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El 'yes ❑ No Dimensions: .... . _._._.. Sludge depth: k_ ... _... Distance from top of sludge to bottom of outlet tee or baffle 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 _.., 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.): ffArm .doc t iev.7l26J.WIB T"tla 5 Offid* r F„"r:Subsusfaace Se"ge DistmW SyWm*Pages 10 d 18 Commonwealth of Massachusetts Title 5 Offolicloal Inspection Form . Subsurface age Disposal System Form Not for Voluntary Assessments Prope rty rty Address ,. � p Owner il7tormation is �". required for every .._.__... � � � � (�......... page c1ty�lown state Zip Code Date of Ilspection D. System Information (cone.) 7. Grease Trap(locate on site plane Depth be WIgra+de: teat Material of cons bon: MM IN El concrete 0 na tat ®fiberglass E] polyethylene ❑other(explain): M yy 'W M iiiiMM _............... ........_,.,,.... .... ......... ,,. ____...._ .......,....,._.........._ Dimensions` �M µ Scum thickness M _....___.__---..._......___...._._._. ...... __........___.._. M w� Distance from trip 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. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.)- 8. Tight or ftlding Tank(tarok must be pumped at time of inspection)(locate on site plan). Depth below grade. _. _ _..........._ _..,,.._ Material of construction: © concrete n metal El fi66rglo F1 polyethylene El other(explain). Dimensions: _......_._ .......,,,,._. _ _ ...._.._...._ ...... ..... Capacity: ga H0ns ., afior Design Flow: i g......_ ......... _ ..... „ __ _....... � t5irx .dot•rev.MW2018 TWe 5 Offidal Inspacbmi Fom Subwdace SewWe DisposalSystem w Page 11 of 18 Commonwealth of Massachusetts .... ....... ......... Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.Not for Voluntary Assessments I�"ropf�rty dcfrry�s p 4iformation is .... . Owner OwrxWs :r l page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 8. Tight ter Holding Tank(coat.) "s Alarm pr El Yes E) No Alarm level: Alarm in working order: El Yes E) No Nate of last pumping: _ _...... . Date Comments(condition of alarm and flo"tcttesn etc.): . ..,_.. .. ...... ...... _. ._.___.._ _._..,..._...._ ._... *Attach copy of current pumping contract(required). Is copy attached? El Yes E No q. Distribution tax(if present must be opened)(bcate 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.): _ w " W C,fWSPA *rev,M26mla TAW 5 MAdd Wh xr Faff:Submirfaw%rmVe System«Page 12 of 18 Commonwealth of Massachusetts Title 5 O f culal In p cUon Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.-. Property Redress Owner Owner's hoe!—. information is C required for every __LL_ ._._._ _. _.. Page. dt0ovan Mete Zip Code Date of Inspection D. System Information (cont.) 10. Purtl�w GhanlN r(locate on site plan) Pumps rn ,w irkirq order: ® Yes ® No* Alarms in working ord e r:. El Yes ® hlo* Comments(note condition of pump chant r, Wndition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Sail Absorption System (SAS)(locate on site plan,excavation not rewired). If SAS not located, explain why: Type: leaching pits number: _..__.... El leaching chambers number. _-----___. ® leaching galleries number: - ___......... _ ..._ ._. ❑ leaching trenches number, length: .. ❑ leaching fields number,dimensions; .. ..... . - ❑ overflow cesspool number: Q innovative/alternative system Type/name of technology: -__. .... ....... _._......_ ........_ t&nsp.doc•rev.'MM2 18 TWe 5 offu.A inspecton Form subsurWe Sevwatp DWposal System.Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Q kit" ..................................... ...... .......... - ------------ ............ . . .. .......................................... Owner information is 2 .................... required for every page- dtyffown State Zip Code Date of inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,etc.): ................................. ---------------- ---------- ye .......... 12. 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 F1 Yes El No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): ................................... ............. ......................... ............... 61nsp,doc-rev.7128/2YPI8 Tide 5 Official trepatsm Forrw Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . Property. _ Address Owner's Name ._ .. Owner , IritR')rrl"Mc'3tlori IS �, ... �.. ,„ required for Kil �oMVn _._. �. �4!.. _. ._.. . _....._....._. _...... . ...._.... .�' ....... e _.. _._ State Zip Code_.. ....___.Date of Inspection D. System Information (cant.) 13. Privy(locate on site plant):. Materials of construction; ........ Dimensions �...,,�.. .. ......... __.. ............ Depth of solids _ ._ Comments(note condition of" oij,1 signs of hydraulic failure, level of ponding, condition of vegetation, etc.); w� .... ..._..-- _. `' ...... _—_._......... t5irtsp.doc•n w.7l2kMIS 'title 5,Offidard kispecdan Fww.Subsurface Sewage Disposal S W Pap 15 of 18 5 Commonwealth of Massachusetts M Title 5 Off"Icalal Inspection Form Subsurface Sewage Disposal System Form-Plot for Voluntary Assessments � d p PF Acidr"ests Owner OmmS lW _ _ ie � .. l _ _ information __w _ r for every twitmfTown state ode Cate,. ..... gage. y of 1 nrt D. Systems Information (coot.) 14. Sketch Of Sewage Disposal System: Provide a tview of the sewage disposal system„ including ties to at least two permanent reference landmarks or benchmarks.Locate all ruts within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. E] hand-sketch in the area below El drawing attached separately _. ., "k, tsEassr.doc.•rev.7/2V M18 TWez 5 OffidW k wpara bon Form,Subsurb"Sewage Diop nwaa9 Syshm•Page 16 of 18 Commonwealth of Maasachluse is Title 5 Official Inspection ion Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prc party Address.. Owner Owner's Name information is required for every __.... page cityfrown swe zip Code Comte of Inspedkxi D. System Information (coot.) 15, Site Exam: ® Check slope Surface water i C (J Check cellar d, .. ❑ Shallow wells Estimated depth to high ground water: p feef Please indicate all methods used to determine the high ground water elevation: E] 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) El Ch with local Board of Health explain ' 7.. .., a ❑ Checked with local excavators„ installers-(attach documentation) ❑ Accessed USES database-explain: You must describe how you established the high ground water elevation: w Before film this Inspection Report, please see Report Completeness Checklist on next page. d'Anewp.doc rev T6",MIS TOW x OftiM m Rarnn Subsuftw Sewaoa' .P 17 18 Commonwealth of Massachusetts w Title 5 Official Inspection =Darr Subsurface ce ages Disposal System Form -Not for Voluntary Assessments Property Address _. _. / dOwner i' rl m .... .. ,, .. information is � required for every page- ity[Towvn State Zip CDde Cate of d E. Report._..m__..�..._. .w.....�._ ........._._...�.__._-__.w.___.__--__..__.._._._...___...._._......_.. ......._...._.. ......_.._ww_.w_ ._.. .um._.._ _.... p Completeness Checklist Complete all applicable sections of this farm inclusive of. A. Inspector Information:Complete all fields in this section. B.Certification: Signed&Dated and 1,2,3,or 4 checked ( C. Inspection Summary; 1,2, 3,or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed 111 C.System Information- For 5:Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5 ga.doc*nw.MAd2 18 TWo S hi . m Fcwm Subsuffaw StwAge D1sjxmW System•magus 18 of 18 ,. OFFICUL INSPECTION FORM- NOT F' I VOID ARY S` SUBS ACE SEWAGE DISPOSAL SYSTEM INSPEC"10�40 F MM W PART C Property Address- Owner: Cate or los �fio*.7�— SKETCH tde a s o sew age a C1w �►l. "" P �a Lmdmark r disposalinc �S es to at l� c� e � . �chmarks.Locate all wells within 100 feet. lw r public water supply s. A --------- P it aA ° r'// ol✓r�G9e/J/ f/�?k