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31 title 5 inspection report 2014 Owner information is required for every page. Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. I5ins.3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Country Way Properly Address Frances Hack Owner's Name Florence City/Town MA. 01062 Nov. 3, 2014 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: Timothy E. Maginnis R.S., LSE Name of Inspector Company Name 70 Montague Road Company Address Westhampton City/Town (413) 527-5291 Telephone Number MA State SI # 1039 License Number 01027 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: ® Passes ❑ Needs Further Evalu (awe Inspectors ❑ Conditionally Passes ❑ Fails Approving Authority re q The system inspector �a.� In� `` ! his inspection report to the Approving Authority (Board of Health or DEP)within 3rtY�iY. eting this inspection. If the system is a shared system or has a design flow of 10,000 gp• • 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. November 5, 2014 Date ****This report only describes conditions at thelime 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 Off icial Inspection Form Subsurface Sewage Disposal System•Page 1 of IT Owner information is required for every page. t5ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owners Name Florence MA. 01062 Nov. 3, 2014 City/Town State Zip Code Dale 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: N/A 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 Check the box for"yes", "no" or tot 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 structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will ass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND(Explain below): N/A Title 5 Official Inspection Farm:Subsurace Sewage Disposal System•Page 20117 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owners Name Florence MA. 01062 Nov. 3, 2014 City/rown 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): N/A ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): N/A 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 15ins.3/13 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 30117 Li) Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Commonwealth of Massachusetts Title 5 Official Inspection Form 31 Country Way Property Address Frances Hack Owner Owner's Name information is required for Florence MA. 01062 Nov. 3, 2014 every page. City/Town State Zip Code Date of Inspection 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. ❑ 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. N/A **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 must be attached to this form_ 3. Other: N/A 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 ❑ ® 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 %day flow ,Sins•3I13 Title S Official Inspection Form Subsurface Sewage Disposal System•Page 4 M 17 Owner information is required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owners Name Florence City/Town B. Certification (cont.) MA. 01062 Nov. 3, 2014 State Zip Code Date of Inspection 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. ❑ Z 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. 15ins•3/13 Title 5°Meal Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owners Name Florence MA. 01062 Nov. 3, 2014 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 following: Yes No ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ • Z 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? 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? 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: 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 495 qpd thins•3113 Title 5 Official Inspection Form:Su dace Sewage Disposal System•Page 5 o117 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence MA. 01062 Nov. 3, 2014 City/Town State Zip Code Date of Inspection D. System Information Description: This SAS was designed for a three bedroom house with a garbage disposal, 495 gpd. The actual load load is 605.89 gpd. The septic tank was most likely installed when the house was built in the mid 1970's. The current SAS was designed and installed in 1944. 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, if available(last 2 years usage(gpd)): Detail: House has been vacant since June, 2014. 0 ❑ Yes ® No ❑ Yes ® No ® Yes ❑ No ❑ Yes Z No N/A Sump pump? ❑ Yes ® No Last date of occupancy: Jun Date 2014 Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present' ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins•3/15 Tine 5 offnaI Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Owner information s required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence MA. 01062 Nov. 3, 2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): Date Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No 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 ❑ Privy ❑ Shared system (yes or no) Of 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 General Information N/A N/A gallons N/A N/A ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): This is an Infiltrator leaching trench system. Six trenches @ 48'L each. tslns.3/13 flue 5 Official Inspection Form.Subsurface Sewage DlsrosaI System•Page 8 or 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owners Name Florence City/Town MA. 01062 Nov. 3, 2014 State Zip Code Date of inspection D. System Information (cant.) Approximate age of all components, date installed Of known)and source of information: Septic tank=40 years+ Leachfield and distribution box=20 years Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): Depth below grade: Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): ❑ Yes Z No 2.5' (30") feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): The sewer pipe is in_good working_order. No evidence of leakage. Venting is proper. Septic Tank(locate on site plan): Depth below grade: Material of construction: ®concrete ❑ metal ❑ fiberglass 1.75 = (21") feet ❑ polyethylene ® other(explain) This is an older septic tank. Most likely, it was installed when the house was built in the mid 1975s. The tank is 21" below grade but a 12" riser with a 24" diameter cover has been installed for ease of pumping. The riser cover is 9" below grade. If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No (10L x 4'W x 4'D) Dimensions: Sludge depth: thins•3/13 Title 5 official nspection Form Subsurface Sewage Disposal System•Pages of 17 Owner information is required for every page. 1Siins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owners Name Florence MA._ 01062 Nov. 3, 2014 City/Town 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 bathe How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): This tank is approximately 40 years old. The inlet and outlet covers could not be removed. Due to the age of the tank it was not possible to verify if tees were present. Covers were cemented and could not be opened. This inspector tried to chissel the cemented covers but was unsccuessful. Any excess force would have damaged the covers and possibly cracked the septic tank. I recommend pumpijg now and every year hereafter. Measured Grease Trap(locate on site plan): N/A Depth below grade: reel Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ 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: N/A N/A N/A N/A N/A Date Tide 5 Official lnspection Form Subsurface Sewage Disposal System•Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence MA. 01062 Nov. 3, 2014 City/rown 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan). N/A Depth below grade: Material of construction: ❑ concrete [' metal [' fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: N/A N/A N/A gallons N/A gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No N/A Date Comments(condition of alarm and float switches, etc.): N/A 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No tsns.3n3 The 5 Official Inspection Frvm:Subsurface sewage Disposal System•Page 11 of 17 Owner information is required for every page. L5lns•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence MA. 01062 Nov. 3, 2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box Of present must be opened) (locate on site plan): Depth of liquid level above outlet invert Liquid level was even with all outlet inverts. 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.): The distribution box is 20 years old and 33"below grade. Its dimensions are (21"x 11"). There was little evidence of carryover and no evidence of leakage into or out of the distribution box. The liquid level was even with all outlet inverts. Overall, the disribution box is in good condition. Upon backfilling the box an orange ribbon(surveyors tape)was layed to show its location. 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.): N/A 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: This SAS consists of 6 Infiltrator trenches @ 48' long each. There is 6' between trenches. It was designed and installed in 1994. Title Disposal System-Page 12 of 17 Owner information is required for every page. tains•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence MA. 01062 Nov. 3, 2014 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.): Eventhough the system has not been used since June 2014, it appears to be in good working order. There were no signs of hydraulic failure, ponding and vegetation was normal(lawn grass). 6©48' long each Cesspools (cesspool must be pumped as part of inspection)(locate on site plan). N/A 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 N/A N/A N/A N/A N/A ❑ Yes ❑ No Title 3 Meal Inspection Farm Subsurface Sewage Disposal System•Page 13 a117 Owner information is required for every page. I5ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence MA. 01062 Nov. 3, 2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: Dimensions N/A N/A N/A Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 10 of 17 Owner Information is required for every page thins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence City/Town MA. 01062 Nov. 3 2014 State 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 S New ?1cz>✓ 0 Title s oricialInspection Form Subsurface Sewage Disposal System•Par 15 W 17 K 9 a 9 r 48 t, 4' pvc solid pip- e a 6 F Distribution box 'D' - (21'x11') a \/ I Existing tank r�n! septic Pumpout manhole ('C') - 24' cover HT �� '149 \\ ck . .‘DeDtoN M `;. �V�\ Existing IIIIIIII'. 11- sewer pipe ♦� Existing Garage 1 3 bedroom house 1 Driveway PLAN ,T :Sidewalk As-BUILT AS-BUILT DIMENSIONS 'A' to 'C'= 26'-0' 'B' to 'C'= 39'-0' 'A' to 'D'= 33'-8' 'B' to 'D'= 47'-0' SUBSURFACE SEWAGE DISPOSAL SYSTEM INFILTRATOR TRENCH SYSTEM 6 TRENCHES © 48ft EACH 31 Country Way Florence, Massachusetts 01062 November 4, 2014 INSTALLER Clifford Clark—Williamsburg, Massachusetts Trench system installed 1994 Owner information is required for every page. thins.SnS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owners Name Florence MA. 01062 Nov. 3, 2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Z Surface water ® Check cellar ® Shallow wells Groundwater has been artificialy depth to high ground water: ficialy lowered with a curtain drain > 10' 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: Dateember 4, 2014 • Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: N/A ❑ Checked with local excavators, installers-(attach documentation) • Accessed USGS database-explain: N/A You must describe how you established the high ground water elevation: -This Inspector did the original perc test and deep hole observations in 1994. -A curtain drain was installed prior to 1994 which has artificially lowered the water table. -Observed no infiltration into septic tank or distribution box. -Elevation of nearby wetlands. -Test pits at nearby property Before filing this Inspection Report, please see Report Completeness Checklist on next page. Tine 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 16 0117 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Country Way Property Address Frances Hack Owner's Name Florence MA. 01062 Nov. 3, 2014 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5im.3/13 Title 5 Official Inspection Form.SubsMBCe Sewage Disposal System•Page 17 of 1>