Loading...
440 Septic Inspection 2001 COMMONWEALTH OF MASSACHUSETT EXECUTIVE OFFICE OF ENVIRONMEN �' » Ia2001 DEPARTMENT OF ENVIRONMENTAL PROTECTIOW ` �. TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: Hy0 ( "U 'l LAM" cv36—' 711-i-me 1 Date of Inspection: 440/ Name of Inspector: (please pri )Pamela f1 Cary Bissell Company Name:_Affordable me-and-Se/0c Inspections Inc Mailing Address:51 Laurel St._ _Holyoke<Ma.01040 Telephone Number: 413-532-8600 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEI' approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Inspector's Signature: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails kriaid.X1111 k S¢y.r. Date: LTA /J0/ 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 is a shared system or has a design flow of 10,000 gild or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments (17i-11,2 ****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. Page 2 of II OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 440 1.(..)aAitivit K� Owner: 'Wstul.er Date of Inspection: `g 4 I�a / Inspection Summary: Check A,B,Q.D br E/ALWAYS complete all of Section D A. System Passes: "`.../ I have not found -information which indicates that any of the failure criteria described in 310 CMK 15.303 or in 310 ' 15.304 exist.Any failure criteria not evaluated are indicated below. Com ts: B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic lank etal and over 20 years old" or the septic tank(whether metal or not)is structurally unsound,exhibit :i rstantial infiltration or extiltration or lank failure is imminent. System will pass inspection if the existing tan replaced with a complying septic tank as approved by the Board of Health. *A met. eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indi• Ong that the tank is less than 20 years old is available. D explain: 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 broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: TU.Jru wti ,s4 fie Date of Inspection: C. 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(0(b)that the system is not functioning in nner which will protect public health,safety and the environment: Cesspool Ivy is within 50 feet of a surface water Cessp t or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic lank AS and the SAS is within a Zone I of a public water supply. The system has ptic lank and SAS and the SAS is within 50 feet of a private water supply well. The an has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private ater supply well**. Method used to determine distance — This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform /' bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of H OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1.624 NI vv. •' '�"Owner: Date of Inspection: 3 I o D. System Failure Criteria applicable to all systems: You must indicate'yes"or"no"to each of the following for all inspections: Yes No I% Backup of sewage into facility or system component due to overloaded orslogged 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 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 1 day flaw _ L 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. _ J Any portion of cesspool or privy is within 100 feet ofa surface water supply or tributary to a surface _ Vwater supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. 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, performed at a DEP certified laboratory,for conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ys.o)The system fads. 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. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or'no"to each of the following: (fhe following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of surface drinking water supply the system is n 200 feet of tributary to a surface drinking water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section F the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. FORM 11-SOftrEVAEF)tki'OR FORM Per OF 3 ENVIRONMENTAL PLANNING ASSOCIATES PO BOX 351 SOUTH DEERFIELD,MA 01373-0351 4131665-7903 COMMONWEALTH OF MASSACHUSETTS Northampton, Massachusetts Soil Suitability Assessment For On-Site Sewage Disposal Performed By: Peter La Barbera Witnessed By: Peter McErlain Date: 6/5/01 Location Address:440 Westhampton Road Lot# Owner's Name: Lincoln&Suzanne Russin Address: 440 Westhampton Road Northampton,MA Telephone# (413)586-8194 NEW CONSTRUCTION ❑ Office Review: Published Soil Survey Available: Hampshire County Central Part Year Published: 1981 Publication Scale: Drainage class: Soil Limitations: Surficial geological report Available: Year Published. Geological Material (Map Unit) Landform: Drumlin/Till Ridge Flood Insurance Rate Map: Above 500 year flood boundary Within 500 year flood boundary Within 100 year flood boundary REPAIR No ❑ Yes 0 1: 16840 Soil Map Unit: Wethersfield-Ho/yoke No El Yes Publication Scale: No ❑ Yes I� No 0 Yes ❑ No RI Yes ❑ Wetland Area: >200' National Wetland Inventory map(map unit) Wetlands Conservancy Program Map(map unit) Current Water Resource Conditions(USGS): Month Range Above Normal ❑ Normal Other References Reviewed: Below Normal ❑ SOILS EVALUATION FORM 7 ENVIRONMENTAL PLANNING ASSOCIATES PO BOX 351 SOUTH DEERFIELD,MA 01373 413/ 665-7903 Location Address or Lot No. 440 Westhampton Road ON-SITE REVIEW Deep Hole No.: 1 Date: 6/5/01 Time: 11:00 a.m. Weather clear Location: See Site Sketch Surface Stones: None Land Use: Residential Slope: 1 -2 % Vegetation Forested Landform Drumlin/Till Ridge Position On Landscape: See Site Sketch Distances front Open Water Body: >200 feet Drainageway: >200 feet Possible Wet Area: >200 feet Property Line: 130 feet Drinking Water Well: >200 feet Other DEEP OBSERVATION HOLE LOG Depth from Sod Horizon Surface(inches) Soil Texture (USDA) Sal Co a (Munsell) Soil Mottling Other (Stricture,stones,Boulders,Consistency. %Gravel) 2 - 0 " 0 — 10" 10 —28" 28 — 102" Parent Material: O A B C Sandy Loam Sandy Loam Sandy Loam Sandy Loam 10YR/5/4 10YR/3/6 10YR/5/4 5YR/4/2 0 0 0 0 Compact in place; Very friable; 20 % gravel & cobbles •MINIMUM TWO HOLES REQUIRED AT EVERY DISPOSAL AREA Glacial Till Depth To Groundwater: > 102" Estimated Seasonal High Groundwater Depth To Bedrock: Standing Water in the hole'. > 102" none 102" Weeping From Face'. none SOILS EVALUATION FORM 2 ENVIRONMENTAL PLANNING ASSOCIATES PO BOX 351 SOUTH DEERFIELD, MA 01373 4131665-7903 Location Address or Lot No. 440 Westhampton Road ON-SITE REVIEW Deep Hole No.: 2 Date: 6/5/01 Time: 11:00 a.m. Weather: clear Location: See Site Sketch % Surface Stones: None Land Use: Residential Slope: 1 -2 H Vegetation Forested Landform Drumlin/Till Ridge Position On Landscape(sketch on back) Distances from: >200 feet Open Water Body: >200 feet Drainageway: feet Possible Wet Area: >200 feet Property Line: 130 Drinking Water Well: >200 feet Other Depth from Surface(inches) 2 -0 " 0 — 10" 10-28" 28 —96" Parent Material Soil Har¢on 0 A B C DEEP OBSERVATION HOLE LOG Soil Tenure (USDA) Sandy Loam Sandy Loam Sandy Loam Sandy Loam Soil Cdar (Mansell) 10YR/5/4 10YR/3/6 10YR/5/4 5YR/4/2 Soil Mottling 0 0 0 0 Other (Structure,stones,Boulders,CalsRlency. %Gravel) Compact in place; Very friable; 20 % gravel &cobbles MINIMUM TWO HOLES REQUIRED AT EVERY DISPOSAL AREA Glacial Till Depth To Groundwater: 95" Estimated Seasonal High Groundwater Depth To Bedrock: Standing Water in the hole: 95" 96" very little Weeping Fram Face: 95" SOILS EVALUATION FORM 3 FORM 12 -PERCOLATION TEST Location Address or Lot No.440 Westhampton Road COMMONWEALTH OF MASSACHUSETTS Northampton, Massachusetts Date: Observation hole#: Depth of pert: Start pre-soak End pre-soak Time© 12" Time©9" Time©6" Time(9"-6") Rate min/inch SITE PAS§ED Performed$y: W itnessS aY: Commeit PERCOLATION TEST 6/5/01 Time. 11:00 a.m. 1 46" 11:22 11:38 11:38 11:52 12:11 19 minutes 7 mpi SITE FAILED Peter LaBarbera P PeterMCErtain SOILS EVALUATION FORM 4 ENVIRONMENTAL PLANNING ASSOCIATES PO BOX 351 SOUTH DEERFIELD,MA 01373 4131665-7903 DATE: 6/5/01 LOCATION: 440 Westhampton Road NAME: Lincoln 8 Suzanne Russin DETERMINATION FOR SEASONAL HIGH WATER TABLE METHOD USED: � Depth observed standing in observation hole inches 2 Depth weeping from side of observation hole DH it 2=95" inches 2 Depth to soil mottles D.H.#1 > 102" Inches D.H.#2 >96" inches 0 Ground Water Adjustment Index well no. Reading date Index well level Adjustment factor Adjusted ground water level Depth of Nautrally Occurrinq Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system ? Yes If not,what is the depth of naturally occurring pervious material ? Certification I certify that on Sprint 1997(date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature t• C U 001,,P t2& Date 6108101 SOILS EVALUATION FORM 5 dia E� XIS I1NG il r___ 11 m / / Percolation test / r �/ / - 50'-2 3/8" f PARK NORTHAMPTON EASTHAMPTON LOCATION MAP 1" = 2000' ± '" e^M aid tls3 VW• • 8d BPB iii 'sa® 4'lt}i'-t en YM�11 Sd f X : -, Ai,. ... • a / BDN�. IM1a '%) B8H + 8Wtl 08H ti J P8w • 1 1 f TA.. �(' T: MHc ..// 1 . 0°M �g BaH �� \ { vat•;.is } ,V` a e8H ers raH 3S1S M rY1 GYM _ �\ e 4•07,1‘ b P. tl i� 8 w pvs is e.� 4 5 S y 1`� �� Cli 1 �+ Il Yfr Ya 5 ad wa1 crAdi r a, aM qf ji a e'dfiF . jeaH ,r BU QV $ f �� ae ' k eee Y v r , �!H e t ey , 3 °/ i = t BeW ` 7!' /M i e'° �( . SaN • . J M ` ' ', . fv: ,Sa2it<•, :,: is r .tiir f ��r 't }p ea TI . .. ,' •is 3 1 6 3 •r ./ ; A ' w� " e M /' ; •7 _ �' `'4 Y }h " ��" Tr ,c '1\��'Lx ' �� 'gyp-V•'-�.:/••1, �.f�` .\4i 0eM te' 0RM. y/ i�.�� '• .M BBH sy' / :A ,YI�IS' R�. q t AB w' 1 my\3a I •N, a\et ve" _ r1t • r•i • •. t• .aP.k • a 7. 2 • AD•.l • • • •71;i1 EN• ., f� / ya • s • ali� /� aai • r i ± fit• . R; a• � \2 -'w"� 'f is ✓.. L _ ` f .._-.. . »tr—a f - • f . Jf J' f. j r..'ti`VK � .X.[. iti I ti 1 ✓$ J 77���_.i.` '4 3 0. . �� ''fit ) il -.... k ` A F 7 r 4 _ ,}• ( . /� / e -it--‘ I "..1 i ';G a i n\ ?-: ' i c_."4,:_,....-... • / ^ f V�1 -'. 1 ev L � C , J 1.::-.1- ;. \-:-..,--' —'---..,,,---,,,.f r� � i r / w a■Ir,,, te---J I 1 0 112 1 1000 0 1000 2000 3000 4000 airkipAsmi ��� Page 5 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:d� Owner: �ra Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yey No r/ 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? Have large volumes of water been introduced to the system recently or as part of this inspection 7 aLA Were as built plans of the system obtained and examined?(If they were not available note as N/Al .✓ Was the facility or dwelling inspected for signs of sewage back up? J J 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,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" Ye@ I no The size and location of the Soil Absorption System(SAS)on the site has been determined based Existing information. For example,a plan at the Board of Health. Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: - •u as Owner: Iawn.wl- / Date of Inspection: 3-5 f a/ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): vtk. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15203(for example: 110 gpd x d of bedrooms): Number of current residents:I_ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no):_iL[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use_(yes or no):(ty ��o� C _ .o ,._. I-.t re -a� Water meter readings, if available(last 2 years usage(gpd)): _ — - Sast pump(yes a no)i(-a 7) Lest date of occupancy: T: COMM ERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow s-. persons/sgfl,etc.):_ Grease trap pres yes or no): Industrial' . e holding tank present(yes or no):_ ,_ Non-s.- ary waste discharged to the Title 5 system (yes or no):_ W. r meter readings,if available:____ _.- Last date ofoccupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): L If yes,volume pumped: gallons--How was quantity pumped determined?__ Reason for pumping: TY/E OF SYSTEM 3/- Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, ifany) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): rtq Page 7 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: iy0 CdL4t�'N K //t� 1 Owner: /0 - Date of Inspection: apt)/OI BUILDING SEWER(locate on site plan) Depth below grade: 3 A-5 Materials of construction: cast iron V40 PVC _other(explain): Distance from private water supply well or suction line: 1 d ' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: 1 (locate on site plan) Depth below grade: 1 '1 Material of construction: /concrete__metal fiberglass polyethylene other(explain) I f tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): _ (attach a copy certificate) Dimensions: /a X SX3 Sludge depth: a If Distance from top of sludge to bottom of outlet tee or baffle: ' Scum thickness: ) ` t Distance from top of scum to top of outlet tee or baffle: $ a if Distance from bottom of scum to bottom of outlet tee r baffle: a t or How were dimensions determined: Comments(on pumping recommendations, miler rtlet to baffle condition, structural integrity, liquid levels as reh ed t outlet invert,evidence o leakage,etc.): fink, „dl Si I 40 P CREASE TRAP: (locate on site plan) Depth below grade: Material of construction: +ficrete_ metal fiberglass polyethylene other (explain): Dimensions: Scum t ness: Di cc from top of scum to top of outlet tee or baffle: stance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4/YO id a-y-n't *'-(° Owner: Date of Inspection: vI d6 / TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal polyethylene_ other(explain): Dimensions: Capacity: / _gallons Design Flow: _gallons/day Alarm pr nt(yes or no): Ala evel: Alarm in working order(yes or no): Date of last pumping: __ Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: P Of 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 ii to or out of box,etc.): ee// 1st t( rc PUMP CHAMBER:_(locate on site plan) Pumps in workin r(yes or no): Alarms in w ng order(yes or no): Comme (note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: YVO (ICJ e Owner / Date of Inspection: v'SH 1/O/ SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) ICSAS 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: Comments(note condition of soil,signs of hydraulic failure, level ofponding,damp soil,condition of vegetation. etc.): Gin 3aF� +y�1 r'e ! �1 x�nw __gr• A � • CESSPOOLS:_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: ..- Depth—top of liquid to in -Tilfwert: Depth of solids laye Depth ofscun . -er Dimensio' ofcesspool: Ma h s of construction: In 'cation of groundwater inflow(yes or no): _ Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY:_(locate on si plan) Materials o nstruction: Dim ons: h of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: W oo V.1r i. Onner: t-JRJ l Date of Inspection: `ill/6/ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. t*Avs_ , a , Page I I of II OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: veto C�axle u id. Owner: tn_xa-i.y/ Date of Inspection: '-T%//f SITE EXAM Slope Surface water 'Check cella'r-, Shall ow we s• [stimated depth to ground water> feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: 7—Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mr�yµ/$S�t describe how you XL-e . tr u-e.; r CO stablished Eh igh ground water-el tion: e�