HomeMy WebLinkAboutConditional Pass - Title V Inspection Report - 440 FOSTER STREET 6/3/2024 ..........................................
Commonwealth of Massachusetts
Title fi a1 Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
gin..
F�
Property Address
_..-------
Owner - s Nerve
information is
required for every
_ _.....
page. CltyfTown State Zip Code rate of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector �pInformation
on the computer, "
use only the talc _ ...... ..., �. � .�.._.... ... I_.'��' ....
key to move your Name of Spector
cursor-do not f
► t .
cr
use a return _�. __
key. Cor p*tf Narne
Cornrivi
City/ own State Zip Code
Telephone one Number License Number
B. Certification
I certify that:I am a DEP approved system inspector in full compliance with section 15.340 of Title 5
(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 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 earl-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ( [ Passes
2. Conditionally Passes
3. El Needs Further Evaluation by the Local Approving Authority
4. El Fails
F'
in, c1.or's signature [sate
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.
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Commonwealth of Massachusetts
Title ► Official Inspection Forte
LL, n
Subsurface Sewage Disposal System Form-pilot forVoluntary Assessments
Property Address
Owner
information iVerrw
required for every .. ._... 1 �"` ,
page. City/Town State Zip Conde Date of Inspection
C. Inspection Summary
Inspection Summary- Complete 1,2, 3,or 5 and all of 4 and 6.
1) System Passes:
164ve,wnot found any information which indicates that any of the failure criteria described
in 31fl 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated beka'hrww„
Comments:
M �
--._ ... ... __.. _..... _.__.__ .
a
2) System Conditionally Passes:
Cane or more system components as described in the"Conditional P`ass"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 tanks is metal and over 20 years:old*or the septic tank(whether metal or not)is structurally
unsound"exhibits substantial infiltration or eAltration 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.
El 'y El hl ® NC (Explain below):.
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Commonwealth of Massachusetts
ToAle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
--_w _.__. _._.... ...__._.__._ _.. ..
Property,Address
Owner CJwn s Marne _..._
information is Y
required for every
(rage. City/Town State Zip Code fate of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cone.):
[ Pump Chamber pumps/alanns not operational.System will pass with Board of Health approval if
pumps/alarms are repaired.
® 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 breaker,, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
M broken pipe(s)are replaced F1 Y Q N ❑ ND (Explain below):
El obstruction is removed [] Y 0 Pal El ND(Explain below):
distribution boat is leveled or replaced n Y F] N (1 ND (Explain below):
--------------
n 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):
n broken pipe(s)are replaced ® Y M N n ND (Explain below):
[ obstruction is removed El Y El N n ND(Explain below):
3) 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..
aw 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:
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Commonwealth of Massachusetts
T "fle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,µ
G roperty Addre I s s
Owner
Owner's Name
information is /vz
required for every
page, Ctty/Town State* Zip Code Cute of Inspection
_._.__._..___.__.,__.... ...__ ..__.._....._._ _............._ ..,.., ___.._.__ ..._ _._. __.._.. ..... .............
__
C. 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. Syste will fail unless the Board of Health (arid Public Water Supplier, if any)
determines the system is functioning in a manner that protects the public health,
safety and envanment:
�] The system has a tic tank and sail absorption system(SAS)and the SAS is within
100 feet of a surface wat4r"Isupply or tributary to a surface water supply.
F] The system has a septicc t ra and SAS and the SAS is within a Zone 1 of a public water
supply.
F1 The system has a septic tank anabk5 and the SAS is within 50 feet of a private water
supply well. NIN
E] The system has a septic tank and SAS a e SAS is less than 100 feet but 50 feet or
more from a private water supply welt**.
Method used to determine distance:
*This system passes if the well water analysis„ performed at a®F certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitro and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems;
You must indicate"'Yes" or"No"to each of the hallowing for all inspections:
"Yes No
[:3 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
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Commw nweatth of Ma►ssachuse is
Title Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ea�w
b
Property Address _.
Owner -------,. �..�
information is � �,
s Mime
required for every _,. ... _r__ 1��wr". " ,� . ...... .__... Y. A.._. _.._ .. . .� .. e . ....__....._._ ..,..
page. Cwty6To wm State dap code taste of wrfs ra
C. Irrptectic►n Summary ( ont.)_n._.______ __..�_.____.._.._....____.__.. ....._.. ._...__.u.,.._..__. r__ _.
4) System Failure Criteria Applicable to All Systems. (cant.)
Yes No
E Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
E Liquid depth in cesspool is less than S"below invert or available volume is less
than Y2 day flow
0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped.
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.
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
F1 t4, Any portion of a cesspool or privy is within 50 feet of a private water supply well.
11 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well%vrith no acceptable water quality analysis, [This
system passes If the well water analysis,performed at a DEP certified
laboratory,for fecal coll°fbrm bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
The system falls.I have determined that one or more of the above failure
1 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.
5) Lange" terns: To be considered a large system the system must serve a facility with a.
design I of 10,000 gpd to 15,000 gpd.
For large sys s, your must indicate either"yes"or"no"to each of the following, to addition to the
question in Sec CA.
Yes No
Q El the system is in 4Utl feet of a surface drinking water supply
D [l the system is within 2 t of a tributary to a surface drinking water supply
the system is located in nitr an sensitive area(Interim Wellhead Protection
11 ElArea--IW is
or a mapped Zone of a public water supply well
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>
Commonwealth of Massachusetts
Title fflr i l Inspection Form
Subsurface Sewage Disposal Systems Foram.Not for Voluntary Assessments
r
Property Address
Owner Owner's Narrwe
info rreation is
required for every _..... ...
pare. cityf N ewvwrn State Zip Cade ate ref i +era
_ .w. ..... __...._...,_.. _ __.,__. _.._ .._,_.,__w_ _ _. _ ___,.___ .. .__,._,_ ............ .. _....... .__..
C. Inspection Summary ary (cont)
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.
6. 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?
Q 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 inspection?
E] Were as built playas of the system obtained and examined?(if they were not
available note as N/A)
E] Was the facility or dwelling inspected for signs of sewage back up?
E] Was the site inspected for signs of break out?
E3 Were all system components,excluding the SAS„ located on sate?
[ 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 Systems(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 unacceptaable)1310 CMR 15.302(5))
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Commonwealth of Massachusetts
µ i �1� Inspection Form
`ail �
ear Voluntary Assessments
' o Subsurface �1asta l straw Form t�Ncat'f
*ra�aray,�a�rir�
a
Owner mar Nam �
irrfwr rmaerrXr is
rcMtAred for . __ .�� _._ ._.__ � � � .., .�... .� �. ._._.. ._...
�
page. Ciayt'r State Zip e ra cry Nrr ocrru
..............
D. System
... _. �1"Ift�N't"Il+c�..._ .__,n._�_______�___.._..�_.._...._ __._...__.._.�....�.__._._..__�-___._a._.....m........___..��...m. ..�_��..._....�...._....�..u._..�
tion
1. Residlontial Flow Conditions:
Number of bedrooms(design): ---- ---- . ..._ Number of bedrooms rns(actual):
.... .. ...
i `Sitai flow based on 310 GMR 15.203(for example'. 114 gpd x#of bedrooms)-
Description:
Number of current rresidents. �.
Does residence have a garbage grinder"? ® "yes Na
Does residence have a water treatment unit? C1 Yes No
If yeas, discharges to:
Is laundry can a seiparate,sewage system?(Include laundry system inspection El Yeas No
information in this report.)
Laundry system inspected? Yeas No
Seasonal use? F1 Yes E No
Water meter readings, if availaiaie*(last 2 years usage(gpd')):
tail:
...... . __..,_..,....._
Sump pump? Yeas No
Last data eaf panty: r aw µ ,
Caaa�
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„ Commonwealth of Massachusefts
Title 5 Official Inspection Form
rch Subsurface Sewage Disp► l System Form•Not for Voluntary Assessments
-�
Propeaty Artrdress
A aer Nance
infomatkon' A—
A for
requin
page- City/Town state Grp terse Cate of rrespe0on
�yst+ r>rn r� `crrnnati+ n
. Cornrrr�atdfrrdustrlaf Flow Co Conditions:
Type of Estabii,4hment
flow b
l . 03):
Design rl f�D
Basis of design flow(seats(pefte s/sq.ft.,etc.).
Grease trap present? El Yes El No
Water treatment unit present? �,. �] Yes [] No
4
If yes„discharges to:
Industrial waste holding tank,present? � Yes �' No
Non-sanitary waste discharged to the Title 5 system? ��� EJ Yes E] No
Water meter readings,it avaiiabls : ......__._.. _.... . .Last date of occupancy/use:
Date
Other(describe below):.
. Pumping Records: c_ .11_( 5,r
Source of information.
Was system pumped as part of the inspection? Yes No
If yes, volume pumped: _ _ ....
pDons
Clow was quantity pumped determined?
Reason for pumping:
,..k
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Commonwealth of Massachusetts
. . .. .............
Title 5 Official Inspection Form
„
Subsurface rf ce age Disposal Systern Form-blot for voluntary Assessments
„ z
F_ir(,g"_1 AddTos
Owner Owrw.Ws Na
information i requked kr 0vtoy .".._ _._._. � , �, . ..._ .2. .........
page. City[Town State Zip Code Date of Inspedpon
D. System Information (cola.)
4. Type of System:
Septic tank„distribution box, soil absorption system
0 Single cesspool
El Overflow cesspool
El Privy
Shared system(yes 6 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 frorn 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.
l father(describe):
Approximate age of all components,date installed(d known)and source of information:
Were Sewage odors detected when arriving at the site? E3 "yes No
. Building Sewer(locate on site plan):
cf
Depth below grade. _-_---
Material of construction
cast iron F1 40 PVC F1 other(explain): _
,
da to from private water supply well or suction line: �_........
feet
onwents(on condition of joints, venting, evidence of leakage, etc.):
6 n,W.dc c•aew 7,12612.018 T de 5 �,�Fww° muofwe�" wM;e r sp osW SFrslarn^Page 9 of 18
Commonwealth of Massachusetts
Title 5 0"'fficial Inspection Form
Subsurface Sewage Disposal System Forma-Not for Voluntary Assessments
Property Address (�
Owner Owner's Na
information is
required for every
i � Date of Ins1.. o _
page. f State Zip Code n
.� .. ... .. ..�. ....._.a�._..(�cant.._.w__...__)�..W..µ�..���..�..w.�_...__.��.. �u..w.�.�_.�.��. .�.��..
D. System Information
6. Septic Tank (locate on site plan):
Depth below grade: feet I..
Material ofconstruction:
concrete ® metal []fiberglass F1 polyethylene other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes E] No
'-
Dimensions: _
rf
Sludge depth: +. .. .,_,.,_........._ ...
Distance from top of sludge to bottom of nutlet tee or baffle -�E
� t
Scum thickness _.. .._ , __._....
Distance from trap of scum to top of outlet tee or baffle -__....._..., _.---
Distance from bottom of scum to bottom of outlet tee or baffle ....C2 ...
How were dimensions determined? _.,..__ ._...__ .._.._w......__._._ ..... _......_....
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity„
liquid levels as related to outlet invert,evidence of leakage,etc.):
..... ------------------
1&tw os -rev.P M201 8 TMe 5 OfficW Inspec6an rax^cer Subsurface sewage Disposat sy twn•Page to of 18
Commonwealth of Ma sarhu tts
Title 5 Official ns c i ► rm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Pmperty Ackiregss
inforniatkm is
rer ueree fore erry
�....__...._
page. iryr ... _ .._. State to p Code D of to ethos n.
D. Sy; ran._Ir�fc�rran; ir�arr..�car�t.� _. ..... ._.m..._w_..�._...�
7. Grea`A "Crap(locate on site plan):
Depth bel agile. I feet
o r
Material of conslr�bkpna
El concrete nl l El fiberglass El polyethylene 0 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 ou
tlet tee or baffle�°'�... .._.. .. _
Date of last pumping: ". .... _._
Corti ments(on pumping recornmend'atiorts, inlet and outlet tee or baffle facer, 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 grade:
Material o struction:
0 concrete etal F1 fiberglass polyethylene other(explain):
Dime=nslsans•
Capacity:
11#0ns
Design low: �. . . _........
ttons per clay
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. , Commonweafth ofMassachusefts
Trials 5 Official Inspection o Form
_ c Subsurface ague Disposal System Form-Not for Voluntary Assessments
Prope dy Addio e
Owner
Na
fequired for eenn ._... .. _ �.... ." .. ..... ._ .
pagee. 6_yffown stater Z a Code rate Inspedion
D. System Information (cont.)
t.)
8. �t or Holding Tank(cone.)
Alarm presto ..w„ El Yes n No
Alarm level: Alarrn in working order: El Yes E] No
Date of last pumping, Data
Comments(condition of alarm and float sMtch ',•e�(c.):
Attach copy of current pumping contract(required), is copy attached? El Yes El No
. 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.):
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gym., Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam•Not for Voluntary Assessments
"�—
Piqmrty Addrms
`' wrraaar 0%wnaaac"s Naan
nfra n �an is
fears �
required
page. tY State Zip Code Paste of Inspection
D. System Information n (cont.)
10. Pump�f Mbear(locate can site plan):
Pumps in working �.�","�. . El Yes El No`
Alarms in working order: " El 'yes [:] No*
Comments(note;condition of pump chamber,condition umps and appurtenances, etc.);
If pumps or alarms are riot in working order„ system is a conditional pass.
11. gall Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
Type:
leaching pits number-
El
leaching chambers number
(l leaching galleries number.
El leaching trenches number.length:
leaching fields number„dimensions: _... ...
overflow cesspool number:
El innovative/alternative system
Type/name of technology:
OWn spAw•rev.'7/2& 018 T" 5 Offimd Wm;*ctm r'sym" mm vfare Sewage ge n:N mysua4 S a ema.Page 13 asr 18
CotnmonvwreaWli of Massachusefts
Title 5 0"'Wicloal InspectionForm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�u mar -, m
Prope(ty Address
xr yA
un red tsar every
State ° Zip
C " Date oaf,Inspection
n tim is
de
rr _
D. System Information (carat.)
11. Soil Absorption System (SAS)(cant,)
Comments(note condition of soil, signs of hydraulic failure,level of ponding"damp soil, condition of
vegetation" etc,):
12. Cesspools (cesspool must be pumped as pert of inspection)(locate on site plan):
Numta r;w and configuration
Depth to W 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, do slit%on of vegetation,
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Commonwealth of Massachusetts
r- `Cite 5 Official Inspection ection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
F'r rty Adritess
owner <„ _. . .
info"nat on ns "
h�r"am/r %
p
rryuureel t every .✓� try b r �• /
page, CwtyF'I own State Zip Carla bate at inspection
D. System Information (cent.)
13. Prlrr i"to on site plan):
-------
Dimensions
Depth of solids
Comments(note condition of sail,"�s ns of hydraulic failure,level of ponding, condition of vegetation„
etc.):
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c mmonwea th of Wssachusefts
Title 5 Official Inspection Form
Subsurface Disposal System Form -Not for Voluntary Assessments
NoWty Address
Owner .. _...
urmdT
requked for every
page, City Town suite Zip(erode tie 4 i
C�. ,system Infwla�rlm�tic�n ( �n�l.}
14. Sketch Of Sewage Disposal System:
Provide a.view of time sewage disposal system, including ties to at lest two,permanent reference
landmarks or benchmarks,Locate all wells within 100 feet,Locate where public water supply enters
the building. Cheek one of the boxes below"
El hand-sketch in the area below
drawing attached separately
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Commonwealth of Massachusetts
l Title 5 Official spec ► Form
- Subsm+urfaee Sewage Disposal Systarn Form-Not for'voluntary Assessments
Rr y Addres
rr Pdrra.._._.... _.
i requri�k ._..w.. t �dd� ddred tip' . /✓�lrP......_
P g . did xrt 1-on
D. System Information cont.)
15. SiteExam:
Check Slope
El Surface water
El Check cellar
D Shallow wells
Estimated depth to high ground water:
Please indicate all methods,used to determine the high ground water elevation:.
El Obtained from system design plans on record
If checked,date of design plan reviewed: CPt� __ _... . _....._.. . ..
E] Observed site(abutting propertylobservation hole within 150 feet of S
El Checked with local Board of Health-explain:
Checked with „ I excavators„ installers -(attach documentation)
El Accessed USES database-explain:.
-_-------- _"You must describe hoax you established the high ground water elevation;
-- _ . ...
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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...... ..._. _... ----........ ..-. ... ......... .....------- _ .....
Commonwealth of Massachusetts
"19 Te 1e 5 Official Inspection Form p
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
Property Address
Ownerem I s Ninfornnation / ,
require furl �+s � T �Code t��t crt
page- ityf row�rrr PI came
F. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
[ A. Ins for Information, Complete all fields in this section.
+ B.Certification: Signed& Gated and 1, 2,3,or checked
C..InspectionSumrraary,
1, 2, 3, or 5 compteted as appropriate
4 (Failure Criteria)and 6(Checklist)completed
[ D.System Information-,
For 6: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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SUBSURFACE S PART C
S ST�.M,INFO TION(continued)
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property Address.
Owner:
Date p lq D ti
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SIETC*j OF SEWAGE DISPOSAL SYSTEM,
wide a sketch of the sewage al� Including ties to at least two permanent reference landmarks or
where public water supply enters the bull�ling.
benchmarks.La all wells within 100 feet-Locate
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