HomeMy WebLinkAboutPass - Title V Inspection Report - 50 BOXFORD STREET 11/29/2023 Commonwealth of Massachusetts
..........
"tie 5 Officoal Inspection Form
T
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Owner Owner's Naext
information is
requred for every J4�)
Inge. Gityfrown State bp Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be aftered in any
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. Inspector Information
on the computer, r",
use only the tab !
key to move your Name of Inspector
cursor-do not
use the return
key.
GwtfTowarn state Zip Code
-----------......
Telephone Number Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 6
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and comptete 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. 0 Passes
2. 0 Conditionally Passes
3. [] Needs Further Evaluation by the Local Approving Authority
4. E3 Fails
C-
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 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 at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5wmp,doc w rev 7 18 TMe 5 OffloW Inspechon Form:Subsurface$ovaga Di l Syuem-Page I d 18
...........
Commonwealth of Massachusetts
ry = ' Title foul Inspection Form
�.
Subsurface Sewage Disposal System Form -foot for'voluntary Assessments
Pr;je y
i a tnformatioar N
Owner �
eq _ de __r M
page Ityf"Fc rr State p Co ti e cr n
C. Inspection 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 CHAR 15.303 or in 310 CMR 15.304 mist.Any failure criteria not evaluated are
indicated below.
Comments.
r A" GC L f
2) System Conditionally Passes:
one or more system components as described in the"Conditional Puss"section need to be
replappd or repaired.The system, upon completion of the replacement or repair, as approved by
the td',of Health,will pass.
Check the box fair'Iy s* "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined„"please W)j;lain.
The septic tank is metal and o�620 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiffrail�q;'or eAttration or tank failure is imminent.System will pass
inspection if the existing tank is replace "With a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if R is st urally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 y6ors old is available.
El [� td n ND (Explain below):
t5insp doc•rev.M&W18 T Me 5 MoaI Inspedm Foffre Subsurfam SwAvqe DmposW*dam<Page 2 of 18
Commonwealth of Massachusetts
Title Official Inspection Form
Subsurface Sewage Disposal System M
-Not for Voluntary Assessments
Owner
Owner r
infearrakion is r � � . 1
� " �° .�..,.._._.__..
page- i own __... State Zip Code Date of a Ton
C. Inspection Summary (coot.)
2) System Conditionally lasses (coat.):
] P6ihp Chamber pumps/alarms,not operational. System will pass with Board of Health approval if
pumWalarms are repaired.
w
�w
® Observation of S"" a backup or break out or high static water level in the distribution box due
to broken or obstruct pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
E] broken pipe(s) are repla �,,,, ❑ Y C] N [] ND ( in below):
0 obstruction is removed ® Y F1 N E] ND(Explain below):
C] distribution box is leveled or replaced Y ® N ® ND (Explain below):
w,
"`Ttap system required pumping more than 4 tunes a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
�] broken .° (s) are replaced E] Y n N ® Nth (Explain below).
Q obstruction is rem ® Y 0 N ® ND(Explain below)-
-
4
3) Further Evaluation is Required by the Board of health:
[] Conditions exist which required further evaluation by the Board of Health in° rder to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.3113(1)(b)that the system is not functioning in a manner which will protect public lwealth,
safety and the environment-.
65insp-doc.rev,MAMI8 Tde 5(Vidal IrmpectionFonn Subsuirlscae, e m 9 System•Page 3 of,18
Commonwealth of Massachusetts
Tale 5 Official Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.P�� i�." #k M1.
Owner Owner's is time
informat for every ion is
requireF 't __. _..._._._._..
page, tY p code of
+ . Inspection Summary (coat.)
� \ 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
b. System fail unless the Board of Health(and Public Water Supplier, if any)
determines that4he system is functioning in a manner that protects the public health,
safety and envirrininvent:
®, The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface wate supply or tributary to a surface water supply,
The system has a.septic t rt and SAS and the SAS is within a Zone 1 of a public water
supply,
E] 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 artd the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determinedistance:
v,
** This system passes if the well water analysis, performed at a P certified laboratory, for fecal
col"rform bacteria indicates absent and the presence of ammonia ni an and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are trigge A copy of the analysis must
be attached to this form.
c. Other
4) System Failure Criteria Applicable to All Systems:
You mast indicate"'Yes"'or"No"to each of the following for all inspections:
`yes No
E 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
t5wmp,doc.rev.MWMI8 Tilde 5 O icid Inspedion F'puara Subsutlam Swooge Dnpasal Symm•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments
A-j
..........
Property Address
Owner Owner's Nam
information is `4
req0red for every 'Y�zl
...............
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6*below invert or available volume is less
than V2day flow
n Required pumping more than 4 times in the last year NOTdue to clogged or
obstructed pipe(s). Number of times pumped:
n Any portion of the SAS,cesspool or privy is below high ground water elevation.
n Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
n Any portion of a cesspool or privy is within a Zone I of a public water supply
well.
n 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,perfoffned at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitraft 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.
n 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 faiture.
6) Large Systems: To be considered a large system the system must serve a facility with a
desibq,fj ow of 10,000 gpd to 16,000 gpd.
For large systepis, you must indicate either Oyes" or"no"to each of the following, in addition to the
questions in Se ,C.4.
Yes No
n n the system"is VMIUQ�400 feet of a surface drinking water supply
❑ the system is within 200 f a tributary to a surface drinking water supply
N'11�
the system is located in a nitrogen's sitive�an I 0�f �rea (Interim Wellhead Protection
0 El
Area—IWPA) or a mapped Zone 11 of a water supply well
t&nsp doc•rev.7/2.2018 TMe 6 OffsaW Inspechon Form Su dace S; Di 4 Sys*m-Page 5 of 18
Commonwealth of Massachusetts
LL Title 5 OfficialInspection Form
w subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Vr jrj�i em
OWrW Owr*r's 17bny�
inrolrnat n is ,
page. CityfTown State Zwta Code Date of Inspection
C. Inspe&1on Summary (wilt.)
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 CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
5. You must indicate"yes"or"no"for each of the following for all 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?
[� Has the system received normal flows in the previous two week period?
E] Have large volumes of water been introduced to the system recently or as part of
this inspection?
n Were as built plans of the system obtained and examined? Cif they were not
available note as N/A)
[ E] Was the facility or dwelling inspected for suns of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?
[] Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, mate",l of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
r Ei Was the facility owner(and occupants if different from owners 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:
Ej 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)[; 10 CMR 15.302(5)]
t5insp d c,rev M26=18 tl Me 5 Y *tnspectmn Form rub a , DmposW S"ystern*F>aage 6 cd 18
C omnnon wea M of MM assachrusefts
Title 5 Official c a sec ►r Form
ry Assessments
� System Form � rats ass wW Subsurface Disposal r�m Meat.for Voluntary
Owrier Owner's Name
required for every 2 .) .w.... _......_._.,,ity own ..... Zip Cade Date of t�ion
page,
D. SystemInformation ...... . ...__._
1. Residential Flow Conditions:
Number of bedrooms(design): _.._._„. plumber of bedrooms(actual): mow......._.._..._
DESIGN flown based can 310 CMR 15.203(fear example: 110 gpd x#of rooms):
Description:
Number of current residents: ............ .._
Does residence have a garbage grinder? [ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes„discharges to. e_....._.... .._._........ ._w......__... .__._._... .. .. .........__... .. ....... _ .._..,
Is laundry on a separate sewage system?(include laundry system inspection
information in this report.) [ Yes No
Laundry system inspected? n Yes No
Seasonaluse? n Yes No
Water meter readings, if available(last 2 years usage(gpd)):
retail:
Sump pump? Yes E] No
Last date of occupancy. Date
` - -
Commonwealth of Massachusetts
.;. subsurface Sewage Disposal System Farm-Not for Voluntary Assessments
ter
( "VI
Owner Name
information as
t _
reqUred for every p e. city frown ...ode.,,_.._ of
.......... ... .�_ ............ .,..__..
State hp
Date
._
D. tarn Information ation (cunt.)
2. Corrtrnu�w�acialilndustrial Flow Conditions:
Type of Establishment: _____ ,.._.r. __.__ � ..___ ... w.
Design
10 rMR 1 a.20 ): _ ,,._.__.. _w..._._..._.w.._._ _._._.......
flown(based c III per day'( tom)
4 s/sq.ft.,etc.) _._.,..,......_._....__.._ _.. -....,.m... . .....
... ...._,._. ._..... _....__...
Basis of design flows se n
Grease trap present? ❑ Yes El No
Water treatment unit present? � ® Yes n No
If yes„discharges to: __.............
_ � ._. ...._... _......,~� ......
Industrial waste holding tank present? n Yes E] No
Non-sanitary waste discharged to the Title 5 system" Yes r No
Water meter readings, if available: _... _...._ ....._.__.........,,w_.__ _..........._..
Last date of occupancy/use: _.._ . . __ ......._ ....__....._. ..... _ .w_._..__
gate
Other(describe below)::
f'urn Records: �� " .,�a.�,.� ,., .��.__... ..
� .�..__�w ._ ,.,_w ....._. .. ._..�._...._. ._ _......_.. ....._��_.._
3.
Source of information: � _........ _....... _........_. ... ......... ...._........_..._.._.._.. .. __ ..._. . ......_.
Was system pumped as part of the inspection? n, Yes No
If yes, volume pumped:
Howw was quantity pumped determined? _ ... _w..____._. . ..w..u..... _._ .._.........._.w.w._... ..._ ._M... _w.._.
Reason for pumping.
T
t�knsp doc-raga,..70'C8 I"Me 5 @:a oc W ftm;xwAm Fmm w»ab%Aacv� G;;br4,w W *Ami-Page 8 of 18
Commomealth of Massachusefts
Title 6 Official InspectionForm
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
_......
ce
... --
_.------
.... a __...... __..,m..._... .: _.__._......w..__._ __w.____.,.....
Pm�rrry .._.
Owner
u .
information' m .
.._� _ .�.. . p�...paw _ ...f o wn stare Zip code tote of Inspedion
D. System Information ation ( nt.)
4. Type of System:
Septic tank, distribution bray„ soil absorption system
[l Single cesspool
[l Ovedlow cesspool
Privy
Shared system(yes o noa)(if yes„ attach previous inspection records, if any)
[l Innovative/Alternative technology,Attach a copy of the current operation and
maintenance contract(to be obtained from systemowner) and a copy of latest
inspection of the I/A system by system operator under contract
(l Tight tank.Attach a copy of the DEP approval.
El ether(describe):
Approximate age of all components,date installed (if known)and source of information:
Mere sewage odors detected when arriving at the site's 0 YesA No
a. Building Sewer(locate on site
plan)-.
pth below grade:
Material of construction.-
34cast iron E]40 PVC n other (explain): __........_ ....... . m W. __.. _. _........ .. _._.._.
Distance from private water supply well or suction line: �� a. _..._mn_.._..____...._...__...._...._.w_
rr
Comments(on condition of)olnts„venting,evidence of leakage,etc.):
tlnr sp,do,•vans.7.2 . 8 7 We 5....W' I Fcwm:Sutwrfsae Swmne D 1 SysWn 9 d 18
Commonwealth ealth of Massachusetts
m^xiFMYM vw
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r�rwa
(eormation is
Owner
req0red for every
.. _. ,
Sude
page- wown Zip Code Date or I
D. System Information tion (cont.)
6. Septic Tank(locate on site plan):
Depth below grade.-
�
Material of construction-
concrete El metal ®fiberglass n polyethylene ]other(explain)
If tank is metal, list age: ___.... _. ...._,.__..._..__.___.____.._. . __..._.. __ .w...w.
year
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes No
{dimensions: ...._..� _......... _ .._.., ...._.._....
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
�n
,cum thickness _. � ..... ...._...... ......._.__. __._.....
[distance from top of scum to top of outlet tee or baffle �...w.•_.--.____ ___v _...
Distance from bottom of scum to bottom of outlet tee or baffle
flovnr 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.):
, .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Sys tem Form-Not for Voluntary Assessments
s q-
................
Property Address
Owror Owner's Na
information M fo 's cpv
r
requil every
page. Qtytrom State Zip Code Date of Inspection
D. System Information (cont.)
7, rease Trap(locate on site plan)-
Depth below grade- - ------fwi"
Material ofcqnstruction:
0 concrete metal [:1 fiberglass n polyethylene other(explain):
Dimensions-
Scum thickness
Distance from top of scum to top of outlet tee or be
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 co n, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan)
Depth below gtadq�
Material of construction.
El concrete metal fiberglass El polyethylene n other(explain):
.............. Z'11......................
Dimensions-
Capacity: gallon s,
Design Flow: ................
t.'"Osp,*X'-vev.M&W 8 t4e50ffbWkrwpechwF*m Su4 damSwwxprimpo",4,lystem.f>age Iloilo
m, Commonwealth ealtht of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner 07,'s Nbbm7'
infbrmation is,
reqLired for `ww _._ _ _e .� .. :� ._....,..... K
page. City/Tomstate__ Zip Code Date or Inspecfion ,
D. System Information (coot.)
& ,.„y right or Holding'Tank(coat.)
Alarm_present, El Yes n No
Alarm level: _... _.... _- Alarm in mirking outer "yes n No
Cate of last pumping: ------ ...._...._ ._...__ ......_._._ ____,_
~� Bate
Comment's(condition of alarm and float sw���Yy etc.).
,attach copy of current pumping contract(required). Is copy attached? E] Yes El No
g. Distribution Box(it present must be opened) (locate on site plaan)..
Depth of liquid level above outlet invert
Comments(note if boar is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Commonwealth of Massachusetts
TRW 5 Official Inspection Forte
M Subsurface Sewage Disposal System Form-Not for`voluntary Assessments
w.a
Property Address
OwnerOwner'sr _y ,.w_w
information is I�prp� ,
k lap _.
retnrer9 f evsryi.. _ . _... �._ _
a _ y Date of Inspection
D. System 1nfcarrrlattion (coat.)
10. Pump Chamber(locate on site plan):
Pump -in- king order° [l Yes ❑ No*
Alarms in working order,. n
n Yes ❑ No*
Comments(note condition of pump chain edition of pumps and appurtenances,etc.),
If pumps or alarms are not in working order,system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located,explain why:
Type:
❑ leaching pits number: -- --
[ leaching chambers number:
El leaching galleries number: -- -- --
❑ leaching trenches number, length;
leaching fields number,dimensions: = -
El overflow cesspool number: ------
El __... w._........
innovative/alternative system
Type/name of technology:
t5insp doc rev 7126=18 TOe 5 CMriar,?A ftp dhion Form Subwdaw Semp D'mposW 91stem•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspectoon Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
...............
Property Address
Owrw "7 et's Name
information is 2
required for every
page. Cityfrown State Zip Code Date of 1;;��
. 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.):
...............
e17
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site,plan)
Number and configuration ............
Depth—top of tiouidjo inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction --------
Indication of groundwater inflow Yes El No
Comments(note condition of soil,signs of hydraulic failure, level of ponding"cp,ndftion of vegetation,
etc.):
---------
...............
-------------
64rmp.doc-mv 71.WX18 Tide 5(Wk-Aal I Fo(m Subsurface'kAmW Drpowd System-Page 14 of 18
rt Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage[Disposal system Forman Not for Voluntary Assessments
�w
Property Address _.__...__..____ ._....___.__.
Owner
lrufomnadurrn is �,� �C ry c
req�Ired for every ___.. __ _.__, ._ ,___ ___.. ___m ._ _..
page, C +frown State Zip Code a of lnsi e a lorA
D. System Information (coot.)
13..,f vy(locate on site plan),
Materials f construction:
Dimensions __..._.._______._
Depth of solids
Comments(note condition of soil,sigs of hydraulic failure, level of ponding, condition of vegetation,
etc.);
t artsq`:b:doc•rev.M2612018 TiVe 5 OffidW Inspection Fcxrrea.:xrsbsudoce Stsvage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f c rty Address
Owner Owner's Name
inforrnaWn is
required for every CV 6
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14, 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
E] drawing attached separately
-4
t5inV,doc-rev,7/26MI8 Tide 5 OffidW Nnspedion F(mm Subsurfaw Sewap Dssposal Sy gem-Page 16 of 18
Commonwealth alth of Massachusetts
Title 5 OfficialInspectio Form
11 Subsurface Sewage Disposal S Form-,blot for Voluntary Assessments
�' e� e
Property Address
Owner 1 rlers rru �� _
inforrnation is P
requiredfor every
page cityrrowvn state Zip a e nt 1 ti n
System Information (cont.)
15. Site Exam—
Q Check Slope
F1 Surface water AJ
'
0 Check cellar
® Shallow well's
Estimated depth to high ground water:
Please indicate all rnethods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked,date of design plan reviewed.- - _., _ _..... .._._ __ __...___..._...._....w._._..
cite
Observed site(abutting properrty/observatiGn hale within 150 feet of SAS)
[l Checked with local ward of Health explain
] checked with local excavators, installers - (attach documentation)
El Accessed USGS database-explain:
You must describe how you established the high ground water elution:
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
f5mw doc•Tvv 7'12W2D18 TWe 5(XhcW prmpedw Fom U .,. r k Syr -Page 17 0 18
Commonwealth of Massachusetts
Title 5 Officloal Inspection Form
Subsurface Sewage Disposal System Fbrm-blot for Voluntary Assessments
Owner �iT
sfV� einformation is � ,.squired for every t;�t Zr ode f e of f Fran
page, rt Fn p C
E. Report Completeness Checklist
Completer all applicable sections of this form inclusive of:
A. Inspector Information:Complete all fields in this section.
1 . 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
D. System Information:
For 8,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
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