380 Septic Inspection 2016 Owner
information is
required for every
page
ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned_Owner's Name
Leeds MA _ 01053 December 1, 2016
City/Town Slate Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary. Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Vacant property. Sump pump in the basement is discharging to the septic system, removal is
recommended as the system is not defined for the additional hydraulic load.
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 approve(
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 tank is metal and over 20 years old`or the septic tank (whether metal or not) is struct
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pas
inspection if the existing tank is replaced with a complying septic tank as approved by the Board
Health
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
Compliance indicating that the tank is less than 20 years old is available.
❑ y ❑ N ❑ ND (Explain below):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
380 Chesterfield Rd
Roperty Address
Bank Owned
Owners Name
Leeds
c ty/rown
MA 01053 December 1, 2016
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.
A. General Information
1 Inspector'.
Norman Bartlett
Name of Inspector
Bartlett Construction
Company Name
109 New Athol Rd-
Company Address
Orange MA
City/Town State
978 575-0888 SI3581
Telephone Number License Number
01364
Zip Code
B. Certification
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 the 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 DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
Z Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
•L ,C _ _ December 14 2016
Inspector's Signature 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 is a shared system or
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 DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""'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.
Title 5 official Inspection Form subsurface Sewage Disposal System.Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned - - — - - - -
Owner Owners Name
information is MA _ 01053 December L 2016
required for every Leeds State Zip Code Date of Inspection page. City/Town
B. Certification (Cont.)
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 tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well
Z The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well
Method used to determine distance: Local upgrade approval dated January 13, 1998 for 75
" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecE
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis
be attached to this form.
3. Other
See attached well water analysis
D) 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
C ® Discharge or ponding of effluent to the surface of the ground or surface w
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an over
or clogged SAS or cesspool
E ® Liquid depth in cesspool is less than 6" below invert or available volume i.
than %day flow
Tare a Official Inspection Form Subsurface Sewage Oapossi System•Pa
on is
for every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address --
Bank Owned
Owner's Name
Leeds MA 01053 December 1 2016
City/Town State Zip Code Date of Inspection
B. Certification (cont)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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
❑ Y
❑
❑ Y
❑ N ❑ ND (Explain below):
❑ N ❑ ND (Explain below).
❑ N ❑ 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).
❑ broken pipe(s) are replaced
obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ Y E N E ND (Explain below):
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.
1. 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:
❑ 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
rise 5 Official rapecton Form Seosurfe=e Sewage Disposal System.Page 3 or 17
Owner
information s
require()for every
page
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owner's Name
Leeds MA 01053 December 1, 2016
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the followir
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Hee
❑ ® Were any of the system components pumped out in the previous two week:
❑ ® 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 {
❑ ® this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were no
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?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the t
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 syst
The size and location of the Soil Absorption System (SAS) on the site f
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
• I I Determined in the field (if any of the failure criteria related to Part C is at is
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
4
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Title 5 official Inapec■on Form suosuna
440
Sewage Disposal System•Pa
n is
yr every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Properly Address
Bank Owned
Owner's Name
Leeds MA 01053 December 1, 2016
City/Town State Zlp Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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 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.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303. therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the 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.
For large systems, you must indicate either"yes"or"no'to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the 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 E 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.
Title 50mual Nspeuion Fore.Subsurface Sewage D,sposa'System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owner Owner's Name
Information is Leeds MA 01053 December 1, 2018
required for every __ .. _ ---
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Last date of occupancy/use.
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped'
How was quantity pumped determined?
Reason for pumping.
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
Overflow cesspool
No info
Date
gallons
❑ Yes Z Nc
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ 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
Tight tank. Attach a copy of the DEP approval.
Other(describe)-
ins mlo Thew otnaal Inspection Form Subsurface Sewage Disposal System•Pa
IS
every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owners Name
Leeds MA 01053 December 1, 2016
City/Town Stale Zip Code Date of Inspection
D. System Information
Description
Conventional gravity flow system with 1500 gallon single compartment septic tank, 2 concrete D-
Box's and a 30 by 42 foot leach field consisting of infiltrators.
Number of current residents.
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings
Detail
available(last 2 years usage (gpd)):
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment.
Design flow(based on 310 CMR 15.203).
Basis of design flow(seats/persons/sq.ft., etc ).
Grease trap present?
Industrial waste holding tank present?
Non-sanitary waste discharged to the Title 5 system?
Water meter readings, if available.
Gallons per day(gpd)
0
❑ Yes N No
❑ Yes N No
❑ Yes ❑ No
❑ Yes N No
Private well
❑ Yes ❑ No
Unkown
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
iee 5 Official Form SJosueace Sewage Disposal System.Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owner Owners Name
information is Leeds
required for every _.
page City/Town
MA 01053 December 1, 2016
State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
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
24 inches
10 inches
4 inches
13 inches
How were dimensions determined? measured with sludge judge
sludge stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural int
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is structurally in good condition as are PVC baffles, liquid level at invert out, no evidence
leakage. Pumping now and every 3 to five years is recommended.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction'.
❑ concrete ❑ metal
feet
E fiberglass ❑ polyethylene ❑ other (e
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
'Sins•113 P9e 5 oriaa Inspection Form:Subsurface Sewage p'soosa Sy•em•Pac
is
every
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owner's Name
Leeds MA 01053 December 1, 2016
City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components, date installed (if known)and source of information:
Septic tank installed in 1992. certificate of compliance for soil absorption system upgrade dated May
27 1999
Were sewage odors detected when arriving at the site? ❑ Yes Z No
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑ east iron
Z 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
1
feet
40+/-
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition, no evidence of leakage, properly vented
Septic Tank (locate on site plan).
Depth below grade.
Material of construction.
Z concrete
❑ metal ❑ fiberglass
4
feet
❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
126 inches long by 68 inches wide
by 51 inch effective depth
6 inches
on Fa'n aoesurface Sewage Disposal Sysen Page cl'7
Owner
Information is
required for every
page
7.5ins 113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Properly Address
Bank Owned
Owners Name
Leeds MA 01053 December 1, 2016
City/Town State Zip Code Date of Inspection
D. System Information (cont)
Distribution Box (if present must be opened) (locate on site plan).
Depth of liquid level above outlet invert 1/8 inches
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryova
evidence of leakage into or out of box, etc.):
2 concrete D-Box's are level and distribution equal, little evidence of solid carryover, pumping t
box's when the tank is pumped is recommended, no leakage observed. Top of the box is 10 inl
below grade, installing risers to within 6 inches of finish grade is recommended.
Pump Chamber(locate on site plan).
Pumps in working order
Alarms in working order.
❑ yes ❑ No`
❑ yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc ):
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why.
rme?Official nsoeamn Form Suosuoxw Sewage Disposal Systen.P
:very
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Progeny Address
Bank Owned
Owners Name
Leeds MA 01053 December 1, 2016
Citvffown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction
❑ concrete ❑ metal
Dimensions:
Capacity:
Design Flow:
Alarm present
Alarm level:
Date of last pumping:
❑ fiberglass ❑ polyethylene ❑ other(explain):
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Title 5 official Inspection Form subsurf ace Sewage Disposal System.Page 11 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owner Owners Name
information is Leeds MA 01053 December 1, 2016
required for every
State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vege
etc )
Privy (locate on site plan):
Materials of construction
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vege
etc.):
Dille 5 orioel Inspection Fa'm subsulece se wage Disposal system.Fag
Commonwealth of Massachusetts
i < Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
390 Chesterfield Rd
Preeeny Address
Bank Owned
Owners Name
Leeds MA 01053 December 1, 2016
rely
City/Town State Zip Code Date of Inspection
D. System Information (cant.)
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 of ponding, damp soil, condition of
vegetation, etc.):
Dry medium loamy sand, no signs of hydraulic failure or ponding observed around or within the SAS
at this time. Normal grassy lawn.
30 X 40 foot
configuration
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan).
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes
❑ No
Tae 5 Official Inspection Form Subsurface Sewage Disposal System•Page r9 or 17
Owner
information is
requires]for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owners Name
Leeds MA 01053 December 1, 2016
OtyTown State Zip Code Date of Inspection
fl System Information (cons.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
3
feet
Please indicate all methods used to determine the high ground water elevation:
• Obtained from system design plans on record
If checked, date of design plan reviewed:
November 20, 1997
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
• Checked with local Board of Health - explain:
Reviewed plans on file
❑ Checked with local excavators, installers - (attach documentation)
Accessed USGS database- explain:
Latest maps available show the SHWT as below normal
You must describe how you established the high ground water elevation.
Soil evaluation by Tim Maginnis on October 10, 1997 determined the SHGWT at 48 inches
original grade as witnessed by the Health Agent.
Before filing this Inspection Report, please see Report Completeness Checklist on ne:
Tue 5 Official Inspection Form Subsurface Sewage Disposal System•
'rY
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Chesterfield Rd
Property Address
Bank Owned _
Owners Name
Leeds MA __. 01053 December 1 2016
City/Town Stale Zip Code Date of Inspection
D. System Information (cont.)
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
well
T
75'
Slope
Swingties A B
ST Outlet 31 7' 32.8'
D-Rox I 59.4' 637'
D-But 2 60.8' 66.8'
Not m Scale
380 Chesterfield Rd Leeds
Tole 5 Official'wpeceon Form subsurface sewage O'spOsal system.Page 15 of 17
Howard Laboratories, Inc.
62 Main Street, P.O. Box 68
Hatfield, MA 01038-0068
Water Analysis Report
howard la borato ri es.com
howardlabs@gmail.com
(413) 247-5533
Cient Boolangers Plumbing Date Sampled: 12-13-16
Sample IC: 18707 Time Sampled: 900
Sample Location: 380 Chesterfield Rd., Leeds MA Date Received: 12-13-16
Sampled By: client Time Received: 1000
Maximum
Analytical Contaminant
Parameter' Result Method Level (MCL) Comments
Tea. Jeiitcrm Absent SM 9223 B-Collilert® Absent OK
Eschehchia ccli Absent SM 9223 B-Collllert® Absent OK
' Parameters included in the Massachusetts DEP Microbiology Certification
§ Microbiology Certification 4: M-00851 for Total Coliform & E. coli(SM 9223B-Colilert®)
Analyst: SBH
Date: 12-14-10
This sample meets the acceptable standards for potability
established by the Code of Massachusetts Regulations, 105 CMR 445.000.
very
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
380 Chesterfield Rd
Property Address
Bank Owned
Owners Name
Leeds MA 01053 December 1, 2016
Clty/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
z Inspection Summary. A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
Z System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
tale 5 official mspe W on Form.Subsurece sewage Dispose)Sysen Page 7 or 17