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HomeMy WebLinkAboutTitle V Inspection Report - 1225 SALEM STREET 4/15/2001 f i . y 4 Y Isi>;b fi Q COMMO TIC OF MASSACHUSETTS �F Eq ,ENVIRONMENTAL AYFAIRS Kt,'a F WARTMENT OF-ENVIRONMENTAL PROTECTION r,. a r 4 TITLE '" ,5, !L"INSPECTION FORM- NPT VQR VOLUNTARY ASSESSMENTS ` STJRS[JRFACE SEWAGE1ISPOSAL SYSTEM FORM r PAIN A CERTIFICATION } f�� y 14p 4 1 A1X .. d .OWAer'#: Iie acigir- 117 12001 y{� r Na ! ' "h dot tJt�,1 1," 1 IJ ►N'STATEMENT'"" AW I have personally inspected the sewage disposal system at this address and that the information reported Qw.14 fff, �Fo:,FQmp 4til f of iqtion..The inspection was performed based on my q^Jy� w n �� pry q a R, # p0per Rtto tad ma ezl q ee�,,pf'on site sewage disposal systems.I am a DEP ve inspector ti { "1 R l �l��5(310 CMR 15.000). The system: J {" 1�i , Passes Conditionally PasseBl,'ti., Needs Further,Evaluation by the Local Approving Authority Fails "..' +�+ D �dtei �M4,"r; " Q'r,1Plie syste� Inspector shall submi copy o inspec 0e1, port to the Approving Authority(Board of Health or 30.days ofcpmple ' g this ins tion.ll tbo system i a shared system or has a design floWjof 10,000 Q",&414fr the inspector and a syste�t+�rvner sl�lll�ul�>nit he report to the appropriate regional office of the ra 4 e 2 f" r sbAuld be setae 0 the system awner spies sent to the buyer,if applicable,and the;approving �aa 1 � �� (�)aclrl ka�s�a�rip kita'�a�era i1a'1 1 1�i auP.` kf� , .. �r° „#'�ap�a�t pn1X d �ribes conditions at the time of inspection and under the conditions of use at that `T�l Iii tiq►p dons not address bPw the system will perform in the future under the same or different r gage � . `�,� ' ON FORM" , NOtTOR VOLUNTARY ASSESSMENTS ACX-SEWAGE DISPOS AL,SYSTEM INSPECTION FORM tt PART,A► IFIC ATIQN(continued) y � . s qqq y 1 � r i� t �r4'G�++. r)1fi11f , fy I iA �� r r + ti 1 rt `X • ., i,a r• s r°! r 4f i} ,i or "�QPIete all of Section D 7 , avo;AOt foun4 any uoTTnation which . ch indicates that tiny of the failure criteria described in 310 CMR ia310,CMR 15.304;xist,An r y failure criteria not evaluated are indicated below. �.• F t f 1 paneuta as described in theµCpAditional Pass"sec U � a00m,up cotnpleti94 of the replacement of ro section need d f replaced 11 > pair,as approved by the Board of Health,will pass. 4 tMrP+ u dstrpa�ued N NA v. ► ► )to the, ;for the following statements.If"not determined"please '+li a ,�; , �� � t}�9�it�,�t�i ter{�. r � '►i;Lt � 1{I',1tt, ,r ,` r, } T1ut+g�apUC tank 1s`metal aua�d over 20 ysacs old'►.ar tbQ se ti tank � P c (whether metal or not)is structurally �. �j � � u ► btts`substantial iuftltraUOA Qr exf"44tion'c tapk failure is imminent.System will pass ins 17 � ,eog ' S t eAlarad with'a complying septic tank as approved by the Board of Health. inspection if the 11 i � A l ! F ta>Ak will pass inspectio�R if it is structurali Y s9uod,not leaking and if a Certificate of Comp Hance is 1043 t1m 20 years,old is avails p , J~ �r it.i- M}Lrj,� ��Z� �,i�.����p°� rr't't�tt •'. 1 F1f j 71 41101116 CI 011f�l . Ii�� 'try IA�ilil.11)!t/ i �f wa8o backup or.break out or hi 6h static water level in the distribution box due to r Le 4404 Or UPOVeA 0,40botion box,System will b o.ten or ,�, Y pass inspection if�w%h , 1�4 , tr��kan ptpe(s�#raped yi 0e10d At'replaced 1 r —43�Y. "�Ti j.� 7�' 15�����1 t1?�t 3{�^. { I ,�i 11,j t111{,'.1 , ` :f. •111 .: 1 � lutrad pWmA mg more than 4 titnea ff fa4 dtu to broken o r obstructed pipe(s).The s stem will NPROVal of u Board of Health). : y , 41.. '. •���'�} ,ut�jrj�;` U' !Z+gpp'�1 �?r'j JM AtAa(s),ttt+o repit4ct~d ObstZWUon is removed ��r{ �� }"� ��'�`�t�� ��;�,e ��' .,�ft ,'�Q���r��'�i��r�►ki[��tk,'3�A11���l�j r I ��E'f1111k4`'{1 1r � � `11.r k r r 3. r i. i •� .lrlj r } } 1 .0�� ;r•'.:� 1 f 1 it 7 J� 6 b y F 9 r 11t IfIJ {��f , 'a� ..7 psi , I did, (?N'IFQ �NC1T: Olt VOLUNTARY ASSESSMENTS 3n £r�, fi URF/t#M,UWAGE DISPOSAL SYSTEM INSPECTION FORM PART 'A CERTIFICATION ATIQN(continued) i I ld f4��1�(''1r1.1'�t rl Y th0 Board 04010: axt�whuFh ' tiuther�vahualioa l�y,-t40 Poard of Health in order to determine if the system public health,safety or the environment. `�*at � & pay►i '' a1��Afoalt6 d4tac �, . accordance with 310 CMR 15.303(1)(b)-that the r ; Ant fusaoanhag in a manner. hich. iF�l r j of I :Y ,i w ;w IP pt'gtect public health,safety and the environment• � :�i � 1��'pttvY.is,�VKttkt�A.SO,f���f a sucfa�+.lt��tat r� , 1 ppogh or privy is within 50 feet of a bond o1Wg vegetated wetland or a salt marsh e M �, ���,i �i �pfi P� �t��fef t ,kn1�4(a. . ♦1�.. t J UH:}{#A�Lr �.°b PkS`(ikl ill .. ', i i' r \ , +7 i 0.Y�i�F �• 1� � �!� i',,�f ta.�,{� lit.; _ �'f.�. r., Y J-- „�dl 1'r 1 ^ o ... {'V �� � 1 ",�5`� � f �•. �;,. I1�VJST..�fl�7{A�I� t � };d,S��,tn�� t1W,Wlt1 tail unheaiu the Board of Heahtb(a mil Public Water Supplier,if any)determines that the ” v �'��,�r ' t►�g0l g a M.4046r that pm4tect$th,0 pupbc health,safety and environment: <�r a�Y,�:atiJ r �er,�` � �l �•� 1 $4ppa Wk eAd soU W AY*M(SAS)and the SAS is within 100 feet of a r l`i , W 'a}►l?F�Y At1b11t ±tea 8latfaGa �akl'�upp1Y• , •, ##APB W*aa¢SSA$aAd,thq SA► :,ia within a Zone 1 of a public water supply. i � ��tv„w��4` ;,r+ .••'"'"'i �M1 Pua aAci SAS 404.91e ySA,S,4 Within 50 feet of a private water supply well. 000% aud,SAS and�.tba$4013,X10”than 100 feet but 50 feet or more from a ' Pp,4 WR1 t , a M�tb►�.(���to g � iP }, °"'T' �'w!T � ( y 'k; p We11 Wac F f aaalYs3s, 9rtiled at a DEP certified laboratory,for coliform ,fir ¢ ' vF1 lA,ergawie camPasads that tbo well is free from pollution from that facility and f "W, o. Mmar"td gen am3 nitrata nigrogett ut,equal to or less than 5 ppm,provided th no other ���y�,` ��' A 9 '.pf.t q a* t,hie attached to this form. ,r 6: t''i MI1 A M1 i.. �Y 1 l L (, b nAp ✓ �� z J , , r , ,l r t ,s l •v 'i�{3�{ y -'�ppi Rr, k rt�ri� a d�� % � � �����S.i•'ri�����fn7/;i�;�Tid�$�b�°fl>>'SrCl7 f � ��' k f ' i. N iQ j� J�x• � { iFgs#ra �nrd tl ttl 1 G 1 r r 1 +i�tl�"i�'UfIi3�;(b� 04 r , K,. )�,',�'{✓�1{�,''ilk f�,���'S� J1W 14J�� i� �4t11'�r.' ' 7 � ,�� 1,�'i , L� "1 i ell 1AU6'INRECTION FORM:-NOT TOR VOLUNTARY ASSESSMENTS 3UPSAC SEWAGE DISPOSAL SYSTEM INSPECTION FORM , l ,♦ 14 PAR f, � PART 7k�. .ti/DDT�yr� R` I CATIO (continued) Y. t th 9'Y �ai#lt'a�rltorla applicable to all systems; 7?fifi' j7A Y /! O ttiao'',to 04011 Ofthol follow ing f i or�unpectlons: 't� r al' !v#8o'iuto faeility'or sYstoat'GOmP9Agnt Niue to overloaded or clogged SAS or cesspool � e m Aong of efluent;o ` s` ;'"�°''; st�."face of ground or surface waters due to an overloaded or .' ° i r i logged SAS or cesspool level!A the distrib4tiop box&W V#qutlet invert due to an overloaded or clogged SAS or ° �' +` {d ` e i cessAgol '` f(P f1(11 t{ta t"Il.''F s C��,.;r. i, • i F �Y x f ui. optb is eosspool is'#ess than 6"below Wort or available volume is less than Y3 day flow j. p:>MPmg�aaro than 4 times in thelast X OT due to clogged or obstructed pipe(s).N Qftutte puA4ped umber ♦ tr4p Of S.AS ' �:Fess for x�x�, Poo prtvy,is�below,high ground water elevation. �♦ r �Y}�PI9rt1on of cesspool or priVy 4 wishm 1pp fat .of a surface water supply or tributary to a surface yK,J2/,�<itl�u'`v 't � � r .!+IT�' PPly�! t {4'1<.�� 'C9flt�t S�► 't!iutd :,al. i # ► �Y, .Af 0 pool .Pri YY is wtthin ' , Q.1 of a public well. Y PQrttou of a Less 1 Poo or privy is within SQ feet of a private water supply well. ' tY 1Qtt.+Pf a cogs l o , vY' than 100,feet but greater than 50 feet from a private water Poo r pn � ess ti �`����''rna�,,��� sy�f�"?���pA�YWell with noacceptablo water ua4 fiaalysis;[This system passes if the well water analysis, DEPicitlfW laboratory,for coliform bacteria and volatile organic compounds !t�►,tut;tho Won lni•fl'ee'frAnn Pollution wn;u"'"�` ,i t,i ' '` ,Altt±Qgen anid uitt'ate nitrogen is equal to or lIM th t facility and the presence of ammonia ;rod.A,� f ess ppm,provided that no other failure criteria ,PY.P the a ngly;ih mkt be 4114,0644 to this form.] T�Q aYstetp ail 1 a M h have'�•�letermined tb*One or more of the above failure criteria exist as 'bid in 3,10 C1v1R 15... ill the the sY0010 fails,The system owner should contact the Board of y;,.49 4C#natwo,what w�l.be nix qQ��/ �p� 3 �1 ^� '° {Aired the failure. .td "� Q �l9y�•������!��t'����j{}}��>i�t�l5linl��`ai�!l��Y;f �'�a!l,��!++,'` },� , f � � ►"����1111r �i T�ry� flt�tiJ H. ai l•:f r)7 lr i'�^ 0,;ystew the Systom Ust serum�p biCili y with a design flow of 10,000 '" gpd'to 1,5,000 cam, P t '"Yosn or"AO"to eagb of We following: ;r. a g ri +��1a1�►fo lame systeuns in 4ddttton to the criteria above) ti ;'i, w �r &,dtiitlUng water supply ' , R e4 y7 TT A w„{� �W�F�w Qu�pl w i0v4 AM,(144r}nq Wellhead Protection Area—IWPA)or a map gd, v. �A "7�R li}fJ rc aM}kW .l pi � , V �� �ah?r�7�i7�, � ► ; j! "1gY,;quooa spa the system is considered a significant threat,or answered oA above tbe:largo;system bas failed;The owner'or o r t Aerator of any large system considered a �r won 8 or failed ���t• r Section D shall upgrade the system in accordance with 310 CMR ?049 should ppotact the el?A F e regional Office of the De partment. j Y � � aft ' is'?i �iy�b.����Y�' �?b n �ti��+5t i'?'`(:rYt7 Y Iii�'�t,l,f�..r 5 • i�v c N d f!t r "91MCla INSPECTION FORM, :NOT YOR VOLUNTARY ASSESSMENTS ' ��~ U AGEr.$AWA►GE DISPOSAL,SYSTEM INSPECTION FORM ' PART a OHZGKLIST t. 0 J }z -- ( � YFw��'�'at���-,l�;�9',x +rt`h k'��;I` ��r,+ ;, J T1 �l� l�.i: . l��l• havC beeA doge.YOU rMijst in "no dicate es"or as to each of the followin '✓� ����1� � iq��, t,{,,I ,t. � ,/ t', 7 r - � fret •C l r M1} f ' �t ;1 tiGa�� 90* a? W"prgvidgd by the Wupant,or Board of Health ,. { °t {, ? �►Qf.tbo SYstcrl COmponOAts pumped put in the previous two weeks? st+ i'i r �V $+ tA iormal flows w h !Qu two week period? jVQ Q Yore$of water been igp oduc, d t, system recently or as part of this inspection 7 �,�• '� plat*of tlto•syst rn obtainod anti oxatuined?(If they were not available note as N/A) r� c� dtl�'Sr„7, 1 r Plilugi gQ �'n��O M,We� *PC"f°�3l�$�Af gWago back up? � t it. }Try" F stto 14specte4,for signs Of bxcak qut?, "r " r system coAUl>piunte,excluding t4;$AS `. orated on site q ; v+., t. ':r p 5 1 it i 5 t>iauholes uncovore o , t � d, and the interior of the � f t#e, eix n4aterial Of QOnstructio tank inspected for the condition D,dunensions,depth of liquid,depth of sludge and d epth of scum? owner(and ! oecupants if dierC�at ; � sowa e s $ r from owner)provided with information on the proper t .`a� ta71a �. 1 } ` � 76. F, ��}'�} rt�.ai��+ �t,11 �lty}4t t,tt� n , g ,�f, '1S3 .li �f � .. • x { � t y +s�Rd lo�ttfon of tpo Soil A bsQrptigR;SYOts��(W)on the site has been determined based on: { Ng Ormaaon.for oxample,a plea itt,the Bs> r of Health. }"� I Y 1 in the Meld(if any of the failure 15,30�(3xb)J ? related to Part G is at issue approximation;of distance 1 yq �t3( h d ` F ( 1 Ski �,( ,r r,y r � •,!s`t 1�' i., .` 1� 1I r �R +, r r 'n.«b�,.ry�i'�-• t 7r; f �n�:'fl fi{ - 1T•�y t �.•' ri } P yk ay��{+', ,�h fl /!�`r '`llS}i fill l��fEl tQl ft�7}�Glfr �J(tt��htY !,u y q�h�}� 1 S r � , , � t f t " � S I r ,•. } k I +.In h z r qy, J , a9 ,+� Jf •.F. , ��f=. �„ r Q '' NN INSPECTION 70 11 NQT%, VOLiJNT '' S $ ,A�,CE.SEWAGE DISPOSAL SYSTEM ARY ASSESSMENTS t z' ; INSPECTION FORM d Aid,7y d 2h °�!q tl t PART is `. n t } , , � `SYSTEM INFORMATION A'r�r - d ` 3 1 f a y^ MINT a '+ k +QW.CONDi'TIONS r } Q�AAI�7AA4F'JAti1:� of be .drum(actual): t o.W bid oIt 310 CUR M203(far example; 110 gpd x#off be'�drooms): f Q�. residents: P ' IY' k i ref� � tinl $ '(yes or no): #Q$WtP w� p,s *m,.(yes or no)U;,Q(tf yes sGpar::,e inspection required] (yes or no) D ((� ��c� h tf,v�Q '�j i My It(last 2 ytw f►usage t'.(gd))r nX V r u RICK y� S ��t +�[�{� •v 'x ye r ?! P't:31 M CR'.1 :� ) Wit(yes Or no); s tk W 401w8cd to th Title --- f if p 4 Ti e�system(yes or no): FF"'.fig 1rM!IIAFR �] � �QM/v��ltwMA�Y1 ' 7 r ll S �� _ � I•i `''►r +iiStio `5 �t�4(►�1 �� dn� « + ' FI ' , � rr t I { ,.4S1 ,Kj.►�ffi3 f���JJL, , , .. � hlt h t ra ;i„� �t �n ♦ i!� ' ilna�sa���rxt J,it1J r�.1V�RAL►W p 1111 Pi ► G � SrdsIiMATIQN S. r V r t d ns c wtion(yes or no)• ! Y YP ?Flxd; 11ons:.How was ' '°� 4ntitY pwupcd determined? i .. , � { ' F�k �b,, =k it y 1r' •(7 t r ?r "r �r� �: FA RIA ( YAs,teach Arpv o2ts 3Asp t-94 records,if any) y operation and maintenance contract(to a ro be p GAy P�tXle L?1r,P M iJ'' uttallpd1�uPwP)and source of information: g7� 1 at �r Alf 44 i`U`t1r A I t t J'�3 ?/b'���rl o a �4a j, dtit id� 4rjft d71�i�,� gad , 'rir KtJ �f i � Ptp; i �• �x y 3 },��f�Y f$��41 f "rA"4C^jC �SA INSPECTION FORM .I rK �-NOT"FOIL VOLUNTARY ASSESSMENTS { WE1►GE.AISPOSAL'SYSTEM INSPECTION FORM '�1L PART Grp., ,, wl p �,� j,( , ' SYSTEM INFO RMATION(continued) yr Vol t e; r 21, - °"' 'i ;"7' '+PR!RMMISP , ir�'�':1-�� i(1 1p l.04' .E� {1 r / 'A !n`; ' ur'1 t�� 6 31V t` 4 , "D ' P�)_:�PAY Well u suction Itns;. owtS Qf lom COAdlt ve,ntan91 evidence of leskagep,etc.) t rr}J'�j''fn%tk�r �.N j�,• I' t t QWAW 04 3 plan) �!i j��SQ-�{�%{�{�L1j i'f•�'�1}r {113:tr T�n ,/9 � ' i y� {y r rb44�?;: co�ncr4to Golyethylene WO, �ppPa asT f `h k:y4r Ie Goof by a C Af Compliance(yes or no): attach a o c py of � " ' So)bp1t0 1 of OtitlRt too or q; 1�� �' i"/ 1 ` .�.s,f��h.•'.f ka ill l(la��-2 ` top�tu top of outlet tw or ' 1 t fry wig, 9RuFt ' "Ag (off FF►�1' $ CAdSt�QAS�tAl t and 0 Bit met kA 9r baffle condition stru I irate i li uid levels M p,� 1 , , „ M t,9Yt+dCACA Of a 4tG. : & 9 �., ] tf f S 1 , - �) 4t r t —11 rr91 ' � l ethylene 1 4 other d�?yfy{�r6 •'i3 j\ tit t ! r , yi, 3 {� • x �- v_,f'lAf��7"1 �sl�l• , 1 ,r.;' /r ,�};i �a; � ! s k. r J '. rr ia4�9 AQ 1=49 top of otttlQt t o.pr ba lg'' .499 .Qf 0M,to bottom of outlet to or b� o�,�" rWr WGt and putlOt op or bile condition structural irate iYdt,oYiau of l qty,liquid levels,, �C CtC ' r r r 5 r k t }' : I r�Ytp��jt zt t!G" 7 �r •r 1 � trt ��t )� I tt pf f�; > � y i,�li.. pp,Y II ,r S•ia rY t../. l i .r ,i. ¢y�� #1� I�1w�>3� st,1{•,t it ,r�{ I# tl I {�?� I 1 ! n bl - �{ r r "L'��.j�', 5 p�1 4fi� 4 trya'if`Q�,�'F S.iU i'iASLU:RFACE N p IN PE ASSESSMENTS f' +q �'' SEWAGE DISP®SAL SYS M INSPECTION FORM '1 FA,i�TL,�r,t•• SYSTEM INFORMATION('continued) ,li1)i 7 i+'.!,} tl.�'1I'i�� 1 ���� 1 ,t,:'• 1�•�• must be urti P,, peg at time,of inspectionxiocate on site plan) �.:9AT<'*'�"�""!�(r � r,1a detP�{1'411iM1 tt i<r:l't tf �r�� �'"�A-�h •i.i�' � yr� � .. ,•- '• .. jgr&g. ,,,,polyethylene other(eXplain): �! Z t. b y/ PAllons y AIR pg�I^ ,rry,^n�.�. As✓day i;!Ir d k JOY • i r —n.r.�-nom , CIJT. or u�worktt order(yes or ao): pMp�nS, aW!t �1 r,� yF) M{U:.`A, u�s�t 1a bi�e Q PI eJ e�.RI a 1 1t! f�k�;.o;t n site plan)3 ; vQ Q%jGt ' � Tavel dud butioo to outlet,equal,any evidence of solids carryover,any evidence of '{ qz%0 { :,:A� �""""1� 7�emlll�l�{ f of� ► R +i; ru�•�` ��t�i�t;{s '[yc�`t���,:y 2�( ; ' ! � 1 .y;, Yqs,Qt 49J fir. ' F , �s!�9�+tea *'r�n(y/��s+��r�:m�►o).��j�� J , r � � J�.,j,. fl s and a urte . { U A• P.. PP na�ces,etc.): r ����� '��a}+��aiJ)l i ,{F�k E, �t4rS1 'v���( �i rt . �r11�4e 1�� 1 t} +�'1 �;�,,j,11,•+: .; {. � l3i '. q, ir��i- t � J i r r � rt ` I 7�• F>t, J, 11 9 , � ; , �Y��14tIt'fi�.rit�lf4� ,Y , tt yk > ' i ;,' '!.�•. ,`���� ly'N tjt,h•�,�G h J 1 S •I t J �� 1 .,t T � ��, r��; � �i• E c�` � IIIt6r ���yJ�a �aa�liutikluiu'+ � 3 x ,�jYl,r�+} �jl� t`r f � it a.s I "` ,: �•1, 1�1 •,.P +A�'<''t i'�il{ � �h (,1�. r r � '. 4 � � �. r 'i rPfJt�'1'. •�r i N�7,S,7'?l�Ra�, +�` I �� v�� , 'fTk'i�+ a t� ra * �,-'x r .. �� p ,i }3 At - rtsh�5a ,� d, �f �r s °er A 1 } h•� atl��t;: b r ''� 1 � t '�,if� 1nry yir..k St ' �1 �a ! !:j T 1 1 t b '04 ��11,, jj y VOLUNTARY ASSESSMENTS s WAFACA SEWAGE]DISPOSAL SYSTEM INSPECTION FORM PART,C YSTEM YF, OR1VUTION(continued) ,. {�J? 91 C �/w'4?llr;! i+ w�w••\ RM1 TI' , 4�A C ndmb 1 'T r1�lb `r;{ ' 1F� r {r �#lY S�' TM(SAS): (locale oglt I lan,excavation no �, t required) � �,i�'t�:L µ �t$f`•.��7,MQ�w 41 ha�3 'n, t e>y �.g.�}�{y 4,,y, � .. �. e 1�cbt1Rt1 .7+n ,. 3 �j �f%`iy(yr{,tU{}+1F �• !r �!t] I JY I � .,f'(t11t �� .f'i,jr{S IrS`H'*. P , •Ar. p 1 ' ; �, fit`!dunCAstAAS: �' }� ,� sspo �µ'Vi' y��; .-.•.a, AYaXtvo%1t Tltativa system Type/natne of technology' �COn¢itiom of soil,signs ofh draulic r I Y &B�►level of ponding,damp soil,condition of vegetation, l ° , i, !,a xz- iTq t 1 l�sspool tttltSt lx P=* ,.as part of Wspecttonxlocate on site plan) ; # A IPF ofiigwd to ingot 1nvcrt:. ON ROL ulads, yw; wata�'ioAaw'(Yes or no), oA of � fly F :f k s�i� 'si�s;o y""'�f ileue level of ondi " dxa�t r p � ng ..ondition of vegetation,e�c.); , 1 t•. � Fad jj ,�{y+:,�tD .�� , 1 � ,:t �yq1 r r Axo �sl ��Hof lovol of pondmg,condition of vex gelation,etc.): '+ iF Y t�14 I{'fAr '2'7r,k `A Ti 1 1 Idqq f � 1 { 1 }� .' tS�l, { y { i ���jj 1 T ,t, • -n , tat`�liX'+�{,'t ., >• ,t,�" i4} ! � ,x' t F..!'.I;1d ''` ti 7 ,1 � j,?u,:'� !I d. { 'rYE.•xa ,lVI." t ;{:�'�.'"�l ��p�17� r 1 ;:�..r,r f I '�I r Q�{, rl• � (,�'•. •s. ( lr * �, 5�' ! 41�FARM . 1tO OR VOLUNTARY ASSESSMENTS I if A,, ,'; '`WAGE'�I�SP0S, 'SYSTEM INSPECTION FORM SYSTEM 3$ OR,11VA�'ION(continued) a-, y •;� 1 .;tint, 1"•� , 7 # FeN N, RYA+ 1�,f�1•i ar t�1 r .If1 `l���y�t� Ib+,�q(1���`,, .; •.. .'t'•r It� '•'.•'+ 3 U it fff(q� 1 I lk !j`�y om d(t ft ,�' +�1Y1��?�� 1r It�A'f�;�1��1.d+���11t"�t/�{��l�p���d{4��{,tF r •�St: j+r':} h'f�!? .r i.A7A ff{7� e t 1 •.r ! > W r 1 t 1 BAR(RCI Og 000 least two �"�� w � �F9 �•PcatF � Permanent reference landmarks or s 1QQ t' W y enters the building. + 4 d 2 '#b � �1�d+>•tll��+tr r� )r t { { 1 ; { t tFWate1'S uPP l r �' >� 'sue� ���t•{fl'i f{}t l ! :t ,Y `'�'�C hiy =}' - , I i A{1 r�z . : fstr rp 1t, , 7 N• I:w � It Q" - s / , . 31 �b,ta V"'sA.M 2 f �ri%`��5. dry;' "I IT"S u' ,1', xn rs qeC!' Ri rI )\ 2A 2y7 it t wl {�'i� T'ry�^ a l{ �a�id Y�.5 t•,tp rte, "a ' � 2 r t ( M1 , t V � �R71C°TA>uK TIES. A.to Inlet Al 31'1" s to Inlet 36'7" ��Ig 'li' rr �'�`It 1 A � w 2 t a A to Center (C1 8 9 a to Center 39 2 to outlet 0 V0 VVYIQt 4215" /� ++ pplayy I� �{ p /� l.2 f ri r�lt { �A iQ 4�Qw j � 'Qr� )J Gi to Box 5012" r t G �? 1 P, h' ��I ? . '+ ,;"' ! r:;,,'_ ,Th+ yatlem is in the rsr yard. rs mr 1 Ott r , I .., ..r •r _ a�, ta:S{1 pr. ��ltYt�9t{��,4���+ ,?r �+.''�t11I {T1.�+1^, �ti k' J�� � r , !!xl S f d 2 j3 n+ ,1+ 7 1 (- rt} .a/ a"`r i+ i d t e T, ���� •�.,,y, 3�Ii' i T i)ti ire 1 I t��+7" {'x,1.1 , I .d -,,,� ,f,.",,,,OF.FICIAL'INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS :I:`' $UBSURFACT SEWAGE DISPOSAL SYSTEM INSPECTION FORM 41 PART C SYSTEM INFO y {, RMATION(continued) 9T� ��''`` uu • 1 1 T� 1�� �}���rl�(f life^P�i} T tP 7;rl I i� .^r ' blond ,X Iwo,� .. �H$.�iri ��k ll,t{ ,,�Ij� � ,.i�t � �I;� Y � �, ts. Ylg��•� �� ��"g"�?�y w�tf �r�lTh�'4r s��.�li''t �1 ��� +� r�• ,' ' .J.1i II Ip QuRd Water feet , Ir , k � Z�4p� �aU xsed to determine e ` r j, {� ? th h<�ground water elevation: f, design plans on record,If checked,date of �bserire ,site design plan reviewed:P ry P AY/obse ati on ole w" 1 S0 feet of SAS) h. ' ' ��:witb loyal aoard of l��alth-explain• Cb* with'local excavators,'installers-(attachdopumentation) USG,S database-explain: 1 i 0 11 C` h ,�s';� you established the high round a ,�� t r W ler.elevatio : � � ��>��fi; 1� �1111h1���1,•.�n� I i' r,+ 1 4r� t II,,. � �, k�. �� t�3,Y���'h�1n�yj�'�I �4r� .fit i , + I �.�i1 tt i t • imz& t 1"# � a111ra 7c' �/ r�( i'r � ;. (,• Ji Y � $ A +1�y".rj:cv ml i •gi+1" Wif A ! }`�(l ei ,1 1i< �, ! 1 t� 4�}I� i S ��.��,.�1• {fie, �a 1Uyt11�11' . "�, il i1,r�N �1)t ilya, tl•� ,1f r 1 , __ �4 a.� w� y, 1• �i'rlA��. r �1 SM r } ¢ F' ng W" . � x s � F �� r I ,, ,. 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