Loading...
7 Title 5 2017 Commonwealth of Massachusetts -f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '7 5///E fin1W5' 11DZ-L..Gw A-04/) Property Address - 7, T�-/FoL t- Owner Owner's Name ` nformat:on is tiZb / c- / / /A 2/ 2 / O 5/o 41e.)/ 7 required for every lj /%/' �P /// oage. • City/Town ,c/G� �G 1 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. Im,ortant:Wnen A. General Information filling out forms on the computer. use only the tab 1. Inspector: icey to move your cursor-do not �J/LL!/g/Y) // f TZ ,D< use the return Name of Inspector key. ��i /zvr7Q �v61�c.)/c sfI I Company Name l V /6 /21Ej ' ;/ /2Z Company Address 14-114- 0 City/Town State Zip Code Y/3 5-y� 18/ 7 Telephone Number License Number B. Certification 1 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 o •- e of the inspection. The inspection, was performed based on my training and experience int - @ t �n and maintenance of on site sewage disposal systems. I am a DEP approved syst:•, :a••c • S••• •nt to Section 15.340 of Title 5(310 CMR 15.000). The system: Sohn N Passes 0 Conditio - y -assess II Fails No.30148 ❑ Needs Furthe aluati by the Local Appro • o t ityetiOeta` essfonal Eng Inspector's S gnature 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. :5.�5•::f10 Title 5 Official Inspection Forth:Scbsurface Sewage Disposal Sys:am•Page 1 or 17 'Commonwealth of Massachusetts i_ Title 5 Official Inspection Form =y—r (�Ui=*= I• Subsurface Sewage Disposal System Form -Not for Voluntary Assessments $i1//E1'/'#/2/)$ // L It 2 /), /J P,epertyAd ass Owner Owner's Name information is , ` � yea n � �al , / v1 01D6D ./� '7 �� required every � 6 �/ page. • City/Town Stale Zip Code Date of inspection B. Certification (cont.) 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 0 Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced KYON ❑ ND (Explain below): O�1,cJS,�Pc 77 44.c% o£Z 11T-6 fZ//1l-/Ei• CGS/O/ 77 ❑ 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): C) Further Evaluation Is Required by the Board of Health: 0 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 Isms•I U1.3 TIO.5 Oficial Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts, Ij Title 5 Official Inspection-Form • s = l=- r►_— Subsurface Sewage Disposal System Form-Nat for Voluntary Assessments 7 Sy /x/02,9 I /71O L60,0 /2-a O Proper.y Address T .Tnc/c- L L-- Owner — J Owner Owners Name Q /. /�Q� required inlormatior is J /iC �l �✓J�/yL sa�1,AI A 0/ -/& page d for every Town � //�/ "/ State Zip Code Date of Inspection pegs. • City.?own 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 ofi 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: • "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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ Xr Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ i 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 ❑ y, , -,Ln Liquid depth in cesspool Is less than 6"below invert or available volume is less A7 /�� than %day flow Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 ---- Commonwealth of Massachusetts , / 1 *-_- Title 5 Official Inspection Form • tn;_. l = e_= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `'t_ �r 7 ‘ 1,,/.6-"r4-4_.05' /��L(O' ) Z L2 Propert r/1dressr/ /cD 6 Owner Owner's Name �J / Q 'squired is A.1694177/..4114,h) 1 i14 a/ OO (5-74 //o/ 7 required for every T-wn State Zip Code Date of Inspection page. � City/Town B. Certification (cont.) Yes No ❑ yl Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: • ❑ X 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 ❑ a izfill tributary to a surface water supply. , , ❑ ViE24 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ /VA24 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 4 2:-.1i4.. 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.] ❑ cm 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 �i 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,��must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No O ❑ the system is within 400 feet of a surface drinking water supply ❑ 0 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 an'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 approprialp regional office of the Department. Tile 5()Aide Inepecton Form:Subsurface Sewage Disposal System•Page 5 or 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,i0/1720 Proper, Address Owner Owner's Name �1J/, information is J , /, AlA IW V/ CJ f� moo' 7 • regt.ired for every /✓Q/`-+' '! � /' page. • . City/Town State Zip Code Date of Inspection C. Checklist Cneck if the following have been done.You must indicate'yes"or"no"as to each of the following: Yes No ❑, & ' Pumping information was'provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently cr 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: ❑ ..1Rr Existing Information. For example,a plan at the Board of Health. ❑ Determined in the field(if 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 47/4/0 .S.,a•1 u t0 Us 5 Oflidal 4wpsc6on Form Subsurface Sewage Dispose!System•Paps 6 cf 17 Z--"-'-Commonwealth of Massachusetts = 4rn Title 5 Official Inspection Form 4 __=tNt Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 7 57/EPnie 475 //Oa2& RD Property Address T . TirjOL L- Owner Comers Name / �� informationeis / /f1� //J X21/2 (J 5 required for every /V n T/L` '1 State Zip Code Date of Inspection page. • �City/Town D. System Information Description: Number of current residents: o 12/:5�U5./2Z 7-0 /9 Does residence have a garbage grinder? JZ 47-44 (//E Ny Yes ❑ No Is laundry on a separate sewage system?[If yes separate inspection required] ❑ Yes X No Laundry system inspected? Xi Yes 0 No Seasonal use? ❑ Yes j' No Water meter readings, if available(last 2 years usage(gpd)): Detail: it)y,/V/1--7". Sump pump? 0 Yes xr No Last date of occupancy: 4Date Commercial/Industrial Flow Conditions:, ,i_' Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? 0 Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? 0 Yes 0 No Water meter readings;if available: t5ms•11110 TO 5 Official Irepeccon Form:Subsurface Flowage Oicposai System•Page 7 of 17 , --TZ--- Commonwealth of Massachusetts ' _r' Title 5 Official Inspection Form . -= q+t-='. =_.= o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 J/ ' ' -' S i>l&Gt..lG Proper�dres.,777 -/---- D1_4- Owner r r DDL 4- 7 Owner Owner's Name / n //J � Q/ information is A /G) v, 41 /� /� o/o�/v �/ caquued ic• every NO /- State Zip Code Date of Inspection page. ,City.Town D. System Information (cont.) Last date of occupancy/use: Date .. . Other(describe below): General Information Pumping Records: N67 GW/1 3 GL Source of information: Was system pumped as part of the inspection? X Yes ❑ No If yes,volume pumped: gallons /-J/. //V U J /7 How was quantity pumped determined? Reason for pumping: Type of System: XSeptic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes,attach previous inspection recgrds, if any) ti ❑ 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): ISins•11/10 Title 5 COW/Inspection Forrrx Subsurface Sewage Disposal System•Page 8 of 17 Y Y --_-. Commonwealth of Massachusetts Title 5 Official Inspection Form id--g--- -E----04,;-----7-_ Assessments —; _ Subsurface Sewage Disposal System Form-Not for Voluntary Property Address y—� / . rikj r::-/"7—bLL /' ^� Owner Owner's Name ,y") d / �% 11 ���� / �` / information is Ai /,/ it/ e Date of InspeCdon required for ever, o State Zip page.. City/Town D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: .. 0 Yes, No Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): d& %/ , Depth below grade: reel Material of construction: '/11 0 cast iron a PVC ❑other(explain): G / Distance from private water supply well or suction line: feet Comments (on condition of joints,venting,evidence of leakage, etc.): Ai0 �44-0 l� /-i S' ,(J©/ice"- Septic Tank(locate on site plan): /0 Depth below grade: feet Material of construction: • ,concrete 0 metal ❑fiberglass 0 polyethylene 0 other(explain) //-9 pC.) /Z-C.. CU/tic AI/a a % di ie. ei // " X 5-- / i If tank is metal,list age: years certificate) 0 Yes 0 No Is age confirmed by a Certificate of Compliance?(attach a copy of8= 1 F/l • X i Dimensions: 7 Sludge depth: T19.5 otfldW Inspeceon Foran Subsurface Sewage Disposal System•Page 9 of 17 bins•11/t0 - Commonwealth of Massachusetts ;-1=- = s Title 5 Official InspectionFormAsses i Disposal System Form-Not for V rY I��� d Subsurface Sewage Disp Y 4,• 11P- , r-./fes P/1/ S /7101---4-6 6C2 Property Address ` oT � � �C/ J Owner Owner's • /%� Q information is State Zip Code Date or Inspection required for every L gage .Cityffown D. System Information (cont.) Septic Tank.(cont.) Z J. Distance from top of sludge to bottom of outlet tee or baffle iy Scum thickness Z /1 Distance from top of scum to top of outlet tee or bathe // Distance from bottom of scum to bottom of outlet tee or baffle ---4---A----t----- it-4/i--0--S-c2 it---el 11 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.): / ` �--/1-6/'n- G °'i'V/ 770'0 T�,l✓� 1 r5 �/�/ �S� l7— 0 '121 6/fWv/I ,UC)1.-- - Grease Trap (locate on site plan): D A...//7 Depth below grade: reef Material of construction: lass ❑ polyethylene ❑ other(explain): D concrete ❑ metal ❑fiber g 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 -nu 5Inspectiondal Inspection Form:Subsurface Sewage Disposal System•Page 1 0117 :Sias.11110 -~•-•-Commonwealth of Massachusetts :� ==_,r Title 5 Official Inspection Form ►_ _� _--�d Subsurface Sewage Disposal System Form-Not for Voluntary ts • Property Address47—C/7:-/C— C/J//}&L y� ` �ry �7 -Avner Owner's frame y� C/ f i / /�` (�'�C6e /010/ / Page. is •. t/` Tr/ �( / State Up Code Date of Inspection required for every Ciy/Town• page. D. System Information (cont.) Ccmments (on pumping recommendations, inlet and eakag outlet tee or baffle condition, structural integrity, Ilquid levels as related.to outlet_invert, evidence ): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete 0 metal 0 fiberglass ❑ polyethylene 0 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: 0 'Yes ❑ No Alarm level: Alarm In working order: 0 Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ., 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes 0 No -no of6da+lnsooQlon Form:8upeurface gewape Disposal Sys;em•Page 11 or 17 ‘5..,,,, ~ `'e. Commonwealth of Massachusetts -* --r' Title 5 Official Inspection Form ,i �viiii Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /f/G /" ' , :S / G--J v(./ Property Address T'. . Torte(3e__e_- • Owner Owner's Name ` information is /tie /J 774/41ijjf�/J VIti Al 0/116 61 6 /'2 2/7 required for every v ,` /✓ �/ ((/J page. . City/Town. State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): • V j' • Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): E /517' Jc ' /36K /,v 0r j>1/ 4•/ /2 C&,L)£7/ )"7D•,v, ,e7c.,,Z.,/9G/S /1-l`" /--7/-i1 o, LX)S?( �141 Pump Chamber(locate on site plan): 0//A" Pumps in working order: D Yes 0 No Alarms in working order: - ❑ Yes 0 No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: • :5ins•11:10 Tpe 5 Official tnspemon form Subsurface Sewage Disposal System•Page 12 of 17 • �� - Commonwealth of Massachusetts __ Title 5 Official Inspection Form -it r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is 4)6/Li 4-/i,/ i /L-pl (Ja/ 5-/4,4.0/ 7 required`cr every page. • City,Town State Zip Code Date of Inspection D. System Information (cont.) Type: • ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: 0 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.): /(/w ig,ee) J ZS✓l7, A10/"— - Cesspools(cesspool must ben pumped as part of inspection) (locate on site plan): Number and configuration ,JA 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 "'S•11:1; Tie 5 011ldel Inspection Form:Subsurface Sewage Ofepossal System•Page 13 of 17 Commonwealth of Massachusetts . 'z, _, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J5///�,"/P/2 f ,/ L 1 C - Property Addr ss . Owner Owner's Name nformation is N �2✓n y �A /4-14 0/ 6 /v6 j/ 420 / 7 requcd for every page. • • .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.): Privy(locate on site plan): 0 414 Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • 15lns•11,10 Tpe 5 OMdd Inspection Form:Subsurface Sewage Disposal System.Page 14 0117 - Y Commonwealth of Massachusetts .0-4:=_ Title 5 Official Inspection Form . p „ -= 'l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • ,,-,'• 9 5/211512i9/2/ 5 // l�.Glcj Property Address Owner - T O/4.:-27---0 G Owners Name information Is 416/2./.771/9f" /- 1(1 J— � 5-76 J• /) //� �yqQI 7 required for every "14C/6 C/ 0 �[� page. • • City/Town 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 i—1 — —7-7- 1 / d ! -- ' -07 t' , ,EGk• 1 0 4 ,,,I1(' , AI -,- "`I. 0 ,� S/e•Pre y`/-- JIc � 5/ - 77, t� i U/_ �Jrz/, 5G //9 . o ,c•;-7., � O ,/ Z o t°.7 "2 \ .."Q \ I \ --cf') Gvi T,/ 40 lZ. h0 r---) D/2/v 115;Oz I 4.-Cicc,/-.)/ /-j • \ AleC) / L/ -v AlJ e /i 151rs•11'10 / -i-ziv//, -i - -� T110.5 OVA Inspection Form:Subsurface Sewage Disposal System t Page.t5 of 17 commonwealth of Massachusetts #=y'llTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Jr , 7 5/ E/2///2- .5" /7/ 6e-crit) ProperyAddress r/ tor. L. �j :.Here Capers Name / /d /i1 7 reformation les / /O 7--/J/F �l /� D f� a j��j a �(�7 Gl age. d fore evert /w! ��-I �7/T /`, gage. Citr,�iown Slate Zip Code Date of Inspection D. System Information (cont.) Site Exam: eck Slope - • L-117-race water • Check cellar ❑ Shallow wells 99 �� ` ��fZ/�—�j0 Estimated depth to high ground water: feet J ,C IA Ger 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: Date ❑ 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 must describe how you established the high ground water elevation: ,51/64..1 G / LII/, /74 404---7-- -71_ 7-77d t //i Sy s 0'1 /(}J oriz/iv� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t:Ir3•'1110 floe 5 Mal Inspection Form:Suosurfece Sewage Clsposal System.Pace 16 of 17 -11. Commonwealth of Massachusetts -'--Trtitsif Title 5 Official Inspection Form ,4 'vt Subsurface Sewage Disposal System Form-Not for Voluntary Assessments mi 7 j/ /,1/ /2/7S /710A} Property Address Owner Owner's Name information is • equired for every ,VOrZJ�t �/2 /l/ u/� oJo /& &t7 page. • .City/Town State Zip Code Date of Inspection E. Report. or� Completeness Checklist I-4i1 pection Summary:A, B, C, D, or E checked • . nspection 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 ISIra•"r'0 Tale SUttidat Inapectlon Form:Subsurface Sewage Disposal System'Page 17 of 17