HomeMy WebLinkAbout46 Foster Street - Title 5 Inspection Rpt - Failed - Title V Inspection Report - 46 FOSTER STREET 11/2/2024 Commonwealth of Massachusetts
-----------
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner Owner's Namp
information is
required for every _/Y_6 kt /CA
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:When
filling out forms A. Inspector Information
on the computer,
use only the tab
key to move your Nam f I ector
cursor-do not 24_7 I
use the return Tipany Name
key. 6, A
V uw GYmp Add SS
0
CitylTown state Zip Code
ricro 50 k 42-3 96 54 1411�- .�
Telephone 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 on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. F1 Passes
2. El Conditionally Passes
3. n Needs Further Evaluation by the Local Approving Authority
&'r
4. R Fails
_Ins_pecitor's aSig-n—atu —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.
t5insp.doc•rev.7126/2018 Tide 5 official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
L 7
Property Address
Owner owner
information is —sName .......
required for every — A �V�
page. city746bwn 7� State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6.
1) Sys empasses:
Fn] I have\nb found any information which indicates that any of the failure criteria described
in 310 CM 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated Belo
Comments:
-----------
2) System Conditionally Passes:
F❑ i Le or more system components as described in the"Conditional Pass"section need to be
p
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box to - es","no"or"not determined" (Y, N, ND)for the following statements. If"not
box
se
determined," please lain.
xp
The septic tank is metal an v er 20 years old*or the septic tank (whether metal or not)is structurally
'a
unsound,exhibits substantial in I ation or exfiltraflon or tank failure is imminent. System will pass
inspection if the existing tank3%Dpel�lcpd with a complying septic tank as approved by the Board of
Health.
I if I is
*A metal septic tank will pass inspection is (ucturally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 y ars old is available.
El Y [I N n ND (Explain below):
ars ol
d is available.
D
—-------------- -----------------
t5inspAoc-rev.712612016 T&5 Official Inspection Form:Subsurface Sewage Usposal System-Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
q ST-
............
Property Address 'elzo--Cs- sl c, c'C-
Owner Owl r's Name
information Is G
required for every 7 Tr------- _1144 ja Date of City/Town State Zip Code Dlf—Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
b E) Observation ewage backup or break out or high static water level in the distribution box due
to broken or obs ted pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(wi proval of Board of Health):
n broken pipe(s)are rept d El Y El N El ND (Explain below):
a n❑
'n s if wa(w g te e
d
ba
ckup ck
pipe(s)pro
u(s
p
va 0 0
r r of
b
d
Bre due Board
t a
k 0
rd
0 a u 0 e
br
oken,
pipe(s)are repi d
t or h
roke
Heai"s In settled ttled
Y
E
obstruction is removed 0 Y E] N 0 ND(Explain below):
El distribution box is leveled or replaced Y El N El ND (Explain below):
- -----------------------
❑
--------------
------------
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):
oken pipes)struc
E] oken pipe(s)are replaced F1 Y [I N F1 ND (Explain below):
F1 obstruc "iremoved n Y El N n ND (Explain below):
.................
3) Further Evaluation is Required by the Board of Health:
El Conditions exist which require further evaluation by the Board of Ith in order to determine if
the system is failing to protect public health,safety or the environmen
'a
a. System will pass unless Board of Health determines In accordance I h 310 CMR
15.303(1)(b)that the system Is not functioning In a manner which will protect public health,
safety and the environment:
t5insp.doo•rev.7/2W2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
"Property Address--—
Owner Owners Name V
information is /U
required for every Date—of Inspection
—-------
page. City/Town State Zip Cad
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ __Sp
sspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will f ' nless the Board of Health(and Public Water Supplier, If any)
5 ! ! functioning
determines that the tem is functioning in a manner that protects the public health,
safety and environment:
❑ Dr le t
The system has a septic tank soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or to ary to a surface water supply.
n The system has a septic tank and SAS the SAS is within a Zone 1 of a public water
supply.
n The system has a septic tank and SAS and the S is within 50 feet of a private water
supply well.
n The system has a septic tank and SAS and the SAS is less an 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 laborat , for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nit gen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the an lysis 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 following for all Inspections:
Yes No
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
El E] due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.V26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
------IG
----- --—----- —-------
Property Address
..........
Owner Owners Name
information Is A��V2� (D
required for every -61
page. i i�An tate Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
1:1 El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
F, F, Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y2day flow
El 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:—.
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
E] E] Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
E] Ej Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
El El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes If the well water analysis, performed at a DEP certified
laboratory,for 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
and chain of custody must be attached to this form.)
El El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
X El The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design f!0 of 10,000 gpd to 15,000 gpd.
For large syst s, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Secti CA.
Yes No
0 n the system ithin 400 feet of a surface drinking water supply
0 EJ the system is within 0 feet of a tributary to a surface drinking water supply
El 11 the system is located in a * ogen sensitive area(interim Wellhead Protection
Area—IWPA)or a mapped Zo 11 of a public water supply well
ecdon F -
15i5sp.doo-rev.712612018 Tile 5 Official Insp:��Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Wo Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
le-S
................ ------
Owner Owner's Name
information Is
required for every
page. citylTown State Zip Code Date of Inspection
C. Inspection Summary (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 C.4 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
❑ 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?
E] )R Have large volumes of water been introduced to the system recently or as part of
this inspection?
E] 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?
❑ Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?
F1 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:
El Existing information. For example,a plan at the Board of Health.
64� ❑
Determined in the field(if any of the failure criteria related to Part C is at issue
F1d approximation of distance is unacceptable)[310 CMR 15.302(6)1
t6irtsp.doc-rev.7126/2018 Tide 5 Official Inspection Faint Substuface Sewage Disposal System-Page 6 of 16
Commonwealth of Massachusetts
-----------
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address 'A
Owner Ow er's Na
information is
required for every
page. CityfFown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
Number of current residents:
Does residence have a garbage grinder? El Yes No
Does residence have a water treatment unit? F1 Yes No
If yes,discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes No
information in this report.)
Laundry system inspected? El Yes No
Seasonal use? El Yes No
Water meter readings,if available (last 2 years usage(gpd)):
Detail:
-------------
-------—-------------------------
Sump pump? El Yes n No
Last date of occupancy:
Date
t5lnsp.doc•rev.7/2612018 Title 5 official Inspedon Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
:- Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
__.._. ...... ..._ 1
Property Address
_. __m.. ..._........
tJwner
inforn
required
atton is Cl /Town StateCodea
Owner's em
required for every �t�-
page ty pDate of Inspectloff
D. System Information (cont.)
2. Com Y'er\b al/Industrial Flow Conditions:
Type of tab Is�Ment: -- _......m._,
Design flow( sed on 310 CMR 15.203): Gauons per day(gpd)
Basis of design flow eats/persons/sq.ft., etc.): ............._--
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to; - __........._.._-..__
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: _._.�__ _m.._._--__._
Last date of occupancy/use; Date
Other(describe below):
3. Pumping Records: t
Source of information: - ---
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: - --- ----------.__.. __
ga a llons
How was quantity pumped determined? --..-_-------- _.___
Reason for pumping;
t5lnsp.doo*rov.1/26/2018 Tide 5 official Inspeclion Form:Subsurface Sewage Disposal System-Page 0 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address At
Owner 0wrler's Nan
information is
required for every Ve-
-------------------
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
KSeptic tank,distribution box, soil absorption system
1:1 Single cesspool
EJ Overflow cesspool
El Privy
a / Shared system (yes,`b-�nif yes, attach previous inspection records, if any)
jl�
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 of the I/A system by system operator under contract
F1 Tight tank.Attach a copy of the DEP approval.
F1 Other(describe):
Approximate age of all components,date installed(if known)and source of information:
k> --------------
Were sewage odors detected when arriving at the site? El Yes 11� No
5. Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
Kcast iron EJ 40 PVC El other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
.............
t51nsp.dGc rev.7/2612018 We 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-----------
Property Address
Owner r-
Owner's Name
Information is Zit kc 2,4
required for every
page. City/Town S tate p Code Date of Inspection'
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
K"concrete El metal El fiberglass El polyethylene ❑other(explain)
---------- -------.........
--------------------- --------------
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes F1 No
Dimensions:
Sludge depth:
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 inegrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
1 � 1 , _ _ _. a" ` .. _... ._._.__.m-------------------.............. _w_.._
-------------
L—A-
6X-0-1
c
161nsp.doc-rev.7/26/2018 Tide 5 Of Inspedion Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- W
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
........------------
Property Address
Owner 0 wn e i's,Nam
information is
required for every
page. -Wtvown State Zip Code Date of Inspection
D. System Information (cont.)
7. Gre se Trap(locate on site plan):
se Trap
(locate on site plan):
p 'r
Depth beld rade: feet
Material of construction:
'o
E]
El concrete 0 metal E3 fiberglass F1 polyethylene ❑other(explain):
----------
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: ------.........
Date
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
---------- -------------------------------
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below�g ------------- -----------
Material of construction:
EI concrete E] metal erglass El polyethylene El other(explain):
Dimensions:
Capacity: --------------- ......
gallons
Design Flow: gallons per day
Wnsp.doc•rev,7/2612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Ownees N"'
information is
required for every
page. dWfown State Zip Code Date of lnspection
D. System Information (cont.)
8. Tight c3 Holding Tank(cont.)
Holding lanKlicont.,
Alarm presen El Yes n No
Alarm level: Alarm in working order: F1 Yes F1 No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
-- --------
Attach copy of current pumping contract(required). Is copy attached? n Yes E-1 No
9. 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.):
CC <"'s
----------
-----------------------------------------------------
............
............. 'A
16msp.doc-rev.h261201 a Tide 5 Official Inspection Fomi:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner O_m wn 's_ erer's—_Name- ..._. L❑• 4. 4 � �`
information is [ j
required for every City/To k —.. _a ✓ (.�c I ( m 'f!
page. own State Zip code Cate of inspection —
D. System Information (cont.)
10.`"A p Chamber(locate on site plan):
Pumps in wo order: Y
p ❑ es ❑ No
Alarms in working order: El Yes ❑ No*
Comments (note condition of pump cha condition 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:
❑ leaching galleries number: -_---
leaching trenches number, length: - -.- ---
❑ leaching fields number,dimensions: — -
❑ overflow cesspool number: ---._-
❑ innovative/alternative system
Type/name of technology: _.._..._.. __ ----_-_.._.-._.___
t5insp.doo•rev.7126/2010 Title 5 4ffidal Inspecdon Form:subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 .......... .........
Property Address
M -----------
Owner Owne(s Name
information is A
MateZip Code Date of Inspection
required for every
page. CityfTown
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.):
V, ......—-----
fw
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Numbernd configuration
Depth—top Of 1_14uid to inlet invert ___..____--
Depth of solids layer
Depth of scum layer
Dimensions of cesspool ——----
Materials of construction
Indication of groundwater inflow El Yes [_1 No
Comments(note condition of soil, signs of hydraulic failure, level of po ng, condition of vegetation,
etc.):
151nsp.doc-rev.7126/2018 Me 5 Offidal Inspec6on Form:Subsurtsoe Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address _....._
Owner Owner's Name
information is � (t
required for every .__. —.-- ___ .
page, Gityrrr ` ` State Zlp Code Date of Inspection
D. System Information (cant.)
13. Privy(locate on site plan):
Materials of construction: _m_ _.._______._.-------------.._._._--.-...._._...-._.--_----_.---
DI gnsions
Depth of tolids _.__.___.._...._..- - --------------------------------
Comments(no ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5lnsp.doc•rev.712612018 Tide 5 O idal Inspection Few,SubsurFaoe Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
N Subsurface Sewage Disposal System Form Not for Voluntary Assessments
LG .......................................... ....................
Property Address a)
Owner Owners Name %*
information is
required for every
page. Citf[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
❑ drawing attached separately
Wnsp,doc-rev,lIP612018 Tide 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
OwnerOwner's Name -'
information is
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Exam'E ite Exam'
F1 eck Slope
4 n Surf e water c
n
Check ar
❑ Shallow well
Estimated depth to hi ground water:
feet—
Please indicate all metho used to determine the high ground water elevation:
El Obtained from sys rin design plans on record
If checked, date of des' n plan reviewed:
Date
F1 Observed site(abutting pr erty/observation hole within 150 feet of SAS)
❑ Checked with local Board of H Ith-explain:
............ -----------
❑
Checked with local excavators, installers attach documentation)
❑ Accessed USGS database-explain:
.......... ------
You must describe how you established the high ground water elXevan:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doo-rev.712612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
----------
Owner Owner's N
information Is
required for every yy
page. City/Town State Zip co'd--e--- J -Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form 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
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
t5insp.doc rev,7/2612018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of ift
I I�4)" O
0 1 tit lJo4)
10�
..............
...........
............
. . ........
-----------------------
01M f
I P
9n�i �. ��'� � �'
��
��, � ,�
.n,
� �r�
°�
� � � P - � �4
,a"', �,I�F I.
� r
- a�� �
' �,.k, 4�"�"9 �rq ry'� 1�,
n v .
�'
/iN�IUF„ � �,/'� � f
�,
� �
� k, �
� !/" 7. M ���u�qr 0
4 � � , 0
A� 1
ask � S�
,�9 ��,
`� mw ��'� ���
U h
r�
,,
� ��
v � �.
��! �,
'=Je
i �''� "�a� � ,�, m�,w
i
// � � a
i�r � r 5 �1� � �,
*� c
1 � �d,� �, � �% `
► ,
���
�--�� ���
°i ,� ��
�� �..
t r"
.,
W
'� ���
,,
,.� � '
� It � ��
�.�b � ��P icy, R
M d �
h �",
q �Y°��'e,�y� �
�y �r� �� 6rt� ' �n � �N �
4 � � 4 ��N NI 1�
�� ��
�w{x r �udP � �r� n 44
�� � �'
���'�� � r � � ,
wax �r� alP, ��B-��
��,��"",�' �,'y���t, a°�I � � �,�' y rn� � y$$ �y ,
N � � �"" �� 'y � ��i �
�R �r �,n � � �,�x
s ^� i " w�m� u I F" F
d�k � p° tl
u
r
x �j��"�� � � r � �� � ��
I�prp � y^�� f �. r��' , b �i�fi�dd,7 �i.����q" �'� l��" a � .� ������� �.
Jp X � 4
q
.' o " � v �
a �°'"�, � �.� � ��rF ,�wd',
�� i Y re ry �
kk��r y'I i���.�'� ��, �� � "� ���"�� � a�'�"� �, a� � ��� � ,��""�M yin r�
v h J � 4a I., k .k ,� " n
� IM
�k�� ��
,.,1'iQ M JN W �
� ��" ��� 1// ' �°'� 5& !"A � r A9 Cep �.�' '.�. � �.o n � �
J� y
F,
.a
a�
� r "� � �e �
N
� � � �
,� � �� �, a� �' � „„, I d,� � <r, � a a �
��p2���� � i d �I�" Nab�� � �P x°��* lea
�^"�1''aP^rr��N" �( ' �/ � a ,. ��� kx' w � i L V i�Wb�7„�a �"6"� �,� ii. ii4.
p " I
r::,,p7 rv(�w�u�1�-. "'"q� ia^' "nod, r,� ..�,'��' �^a�"��', t"n""„..,k d!`� v�,„� ',M ",y~ - ",&. '""Y,4„ �,r/G�"�'9'jF" µureA,.;' G„y �.M q"� m�, ',,d,� ✓„�` �,, 'af,; �.„„, � ,' «°x" �:{ "�" '..;;�S��s'`t ,�V,kx "m".m .:;� r� v , ,,a�'. y!a S'+�.w"l�^.x^„ ,✓ 3r"='""kt^r�ar ,,d�' ,n�'1 ,1'fi�ry�'m'� '1:
',
r',✓.."' r.,' cpp � t,.. ,w"
^'
�ri, ,<'fP�� �W�.. � ,,.. :m rq"e�,Nnw ° ,ywtij n�d,M `�� � � ,1""e+ 'i" f'�r., ,✓� ,V � '.yY",e`°�,ymw,, 1�„m, j ,r^I�a y u�o "6.� m, m",�1j�� y'
p�" I;rx"" r,� w,•'W�„''* J°� � dr + / a, ,+ B.rw�{'X"F�, ��" �+ �. ��,a ,u"w`r'�,^, .,x�"� ' �d"y,,a'%wi> �m�. I 6`m F,r 'a,�i r "' �"`"i�(»��'w,�;,
w ^
�bl��.. Y P'S"".,✓. �. pr`" fa' M awry lq " x
u 4✓r,M � w p � n - a
�,.w a7� "M, �y�'� �,{, ^rM"� a '.: d" q� ''(�tl'w �✓ t �;� wY x y r�t+''a` �, ,�r"a rP x,✓ r� w �are�,n �x ti� '/' rY"',yr�",>rf..°;'`
� � ��+.- � ✓ Gl�{,yp� '�"' (p x a M` „ �*^ ✓ r r ^W. �„�� � :w"� k � -.�, �k`� �mn b+.;"�„
I, ';",d E °b Ir:°, ✓ N '„� ,(` YF :,,� °r .`6 �a a 1CM.""'p :�. ;'d,al� 'C ;�,'t� 1" :�W .✓� ""'� *M^ �,. "'"✓ Yt �'"":W`�"� d-, 1 ° '..
4 „ d Fw 4..ua ! xza ,ab r;, ";q.''. C.,x,:: " uFn.y✓1`.x "u' .' ` f ,w,-,'>,.,"` l". .r „^'+" a�,,,W„r °,8 s:,r,.Y"ry ✓rC',. pP` I N u .,Iw"b,:,�✓ a .,) Y�„ 1r $`PY _rp ,,riu >�N. „�" w v�t'aIr' �;.. ufi� � .,r � n� �m �'" G� �p ✓ 'rri!p h"�.I/ °, ,,;in. r a „"!rim h+" �� *`,n
r1
,rm/ ��;,'^�. M�" w� �� x°�ta N„.F , �P* dy r,�:a.��x,;,,, N � u'a .!,'/" � ,i �n,�1,�r* ti�'1'",�"✓"'�" :R,. ' ,M„
W t° v;,,'w✓ mw, . °{ ah'"d + x��r„,�-,�,? p..yt," ��-, ^d mh";Mg�mll, <r�� ,n '� 1+ ��m « � � '
�re m,¢ < � 'I'"y;�a •-,C ,� rrc��;+ ,�'0 y6 w�""ar,, ✓ m�„ �W, ,� n�ra,� y -Ge ry F+,.vr,��l`„".« `mN 1 eM '�'w "�`'�.,� ,� rex a "�;na
e p"'�r r,'�„x s 1 � ,:' ,�',��y �, 7y ;��' "+'*P r�,�q"', F�, p„r..m i °` ,x•?'i '�.;,,,," r�yi �yd`,� r r� o u+ H,
� � r A r �a�` ✓ w w a$ m � ✓ i,�"" r""re � o
"
�����re � °,4;"ag o u . ""�;y x✓ r yr> ra ,?��r�' i�" I��p �x�r� �,�'�� r"arn r �
r a � 1 1 " I � ',. rW r'W p!"" y, b rrW r m4 ✓
mtx r� 1 1 w r r "�«!fy a � � �p✓v M
I 'f�7q... � �� A,y'r���i w�'rr Ip�j�✓� lip � �pr�r %m a W t >""wv
a i m �y�rd 1 u re r
.�r➢,gyp /err � �� ,rri m rm fr��'�,F'`� � a M "".ro r�,"°4 ��+�,�`r"
a' I r / '�r� 'q 1 ,l/� G ml✓ r Frt G �� J ,r �. �wp�I�� n
G�,m�`tp.y, f , � '� t ;3 mW Fs m!a Fp r m�� `�'�{ �✓ , 4���a
p',�J '"« I 9�r�r l�r r / v ret t,✓ �g�r y � � m'i �+x!rr � f ��
PAP W,
r.^ym" ,/ ra✓ r r r h r*m. a r w, �ryi b ro rl M(d «
� r� µ �✓��� ;r��rei ri y a pay, Y pn'� d� ;�rjp ✓Y� a � t' t, my��M ""'w
r, 4"W ✓ � V w 1 "mi,� �i I !���;�ri/k 1 r,�' ^�"�y ,n a,,,,a r���ads,�°_«�
rn 9��sr r J � °x e," "" d rr p", ✓�� .�d � w "` �yJl r�,d
1 S,� r r r tl ✓ q*r /, P , a w r;✓/��` p
"" � ��; / " ,e x �ywA ere° x�'�"'��9�ur'k�" �:.✓r"1/ � �� r� ��' �9� 1/i�/%to i���
�rlri/r r�a `� �✓� � t°����� �„� � a i r r fps % �a
,$$ r
F W
� �/ y
r� G�
50
�,w� « %u� ^��� r � a✓ n�J t a p�"�
° a
r
I
h p
�J' (�w� 4 1�h•''; roy
l
a r
+a 4 r r l� ✓�
Im r, '" I k fl � r`y m4 R,a"k r �m �✓ � �r I 6 wu m ( I rl�
,
r
u w ,
y
I ' m
gip, ,u ✓ ', N
r jiV ,
✓
r /
fir, � VY1)'�t� y✓�� „',,,,,y ✓��� Waif�l�F r ���1'��IR�r�I- 1 ,l�Vw, ma:� y� ,t. �;;^, r�,�u✓ r ' �
J
r
'�.,��' „g �A`"M ,�rXw r r:•% '"mh5�':�^ / �C!��"�."Ytl��� ��*'�J ,y �P��^,�" �9"""" �» ., '. "�� �, ��„"J i;'� J' �a }�r� „;^ '-a
��N��,",,;" - �`a�, „�,n"„r `p. "�<^� a ,.',;I °:"� "✓"*'p 7A a".;Y"�ww �`'°,4'���r`1,r✓w, „��+ ? ",% t, � _ �µ fi���" 4�.ro,� s�. ��,„"d. `^, � " �" � �i ,r
�' ^rtk / °/`:. •'.v.'N,.� r . ,+ +°., „u.," ,,.»t nr A� ���- 'usa �,��" " ,�m �r' �6'+�^w�"k" k -'.,r" ,r�xT'�,�,�1y ",arA� �N,;a�+,�'� p�'a !��.. ,
I �
""�;" *m'a'"✓ �i'%,""��b� a' °' �„" ,Yd� ,k`N� �., ��l"r "�' y "a�GY� uw '�: .R.,y"�A� " aor �+, a w rr-F a a/ '� ',a�"4 r'r
ro'f'✓t+"p�y�`+k �'N/y w�," 'f �� Al � y ��,�rr�t/�! Vw✓b�»CA � "' """ m .:, `a�*"��»°
d° r
"
f
"
m " r
^ ri i
�f R ✓
� a
PF✓„rxd mY" * aaa �,'eV" u N r/
U
i l
r a"ay9%�w•+✓vN F rf�� p�q"jrr7"" a f s ,'.� / /
>" r✓ar a I r �'Y� / r��/�f ��"w6w "f �`p �i,�, t "� ',.
a
a r
v'
i
p
7
o v'
/
Aodfl r