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Currency [0]/Explanatory TextG5Explanatory Text %0 : Followed Hyperlink 1Good;Good  a%2 Heading 1G Heading 1 I}%O3 Heading 2G Heading 2 I}%?4 Heading 3G Heading 3 I}%235 Heading 49 Heading 4 I}%6( Hyperlink 7InputuInput ̙ ??v% 8 Linked CellK Linked Cell }% 9NeutralANeutral  e%"Normal :Noteb Note   ;OutputwOutput  ???%????????? ???<$Percent =Title1Title I}% >TotalMTotal %OO? Warning Text? Warning Text %XTableStyleMedium2PivotStyleLight16`w Page 1 Final Page 2 Final< Page 3 FinalͲ Page 4 FinalPage 5 Site Sketch` Checklist Supplement   ;#  ;M  ;-  ;)  ;`i GPROPERTY INFORMATIONAddress: Municipality:County:Current Owner:SYSTEM INFORMATION Type:Dates:Designed PermittedTreatment Tank:Disposal Area: Designer: License No. Installer:INSPECTION INFORMATION Findings: Conclusion:/Subsurface Wastewater Disposal System InspectorDateINSPECTION ITEMCOMMENTYESNON/A1 System Records Search Donea. Design Plan Existsb. Permit Existsc. System Inspection Record Existsd. Maintenance Records Existe. Water Use Records Exist2 Internal Plumbing Review Done Garbage Disposal Present Water Treatment Unit Present All Fixtures Connected to Systemf. Plumbing Fixture Leaks OK3 General Condition OK Size OK Access for Pumping OK Liquid Level OK Solids Level OK4 Pump & Wetwell Present Alarm & Circuit OK Access for Service OK Float Switches OK5 Disposal Area Present" Effluent Contained Below Surface Ground Cover OK1. System Records Narrative:%(Use additional sheets as necessary.) 2. Internal Plumbing Narrative:3. Treatment Tank Narrative:4. Pump & Wetwell Narrative:5. Disposal Area Narrative:System Location Sketch Scale: 1" =Obtained from Client4Conclusions Drawn from Records Search and Site Visit Water Supply Setback OK Major Waterbody Setback OK6. Findings Narrative:GPD/ /Vol. Cert. No. Last Name: First Name:.Collected During Records Search and Site VisitGALDesign Capacity _________ Permit No. Current Use:1.a1.b1.c2.e2.f3.a3.b3.c3.d3.e3.f4.a4.b4.c4.d5.a5.b5.c5.d5.e!System plan unable to be located..Certificate of inspection unable to be located Tank undersized for current use.!Pump and alarm on common circuit.%Malfunction per Chapter 3 Definition.%Float switches inoperable or missing.%> 12" excavation needed to pump tank.(> 12" excavation needed to service pump.Pump inoperable..Plan with permit sticker unable to be located..Plumbing fixture(s) not connected to a system.,Plumbing fixture(s) with water supply leaks./Solids and/or scum exceed 1/3 of tank capacity.+Pipe, stone, or proprietary device exposed. Liquid level above inlet invert. Lot Size: Tax Map No.:Lot No.:!Malfunction per Rules Identified:No System Deficiencies Noted.YES )Corrective Action Recommended See Page 4 1 Records 2 Internal3 Tank4 Pump5 Fieldd(Use additional sheets as necessary. Relate Noted System Deficiencies to Appropriate Rule Section.)Baffles damaged or missing. Baffles OK Treatment Tank Present Clothes Washer Present Structure Currently OccupiedSystem Deficiencies Identified:0Cracks visible in observed portion of tank wall.UNKN*1Disposal area subject to visible surface erosion.]On the date noted below I completed an inspection of the subsurface wastewater disposal system serving the subject property. The inspection included a review of property owner, municipal and state records as appropriate and a visit to the property. This report was completed in accordance with minimum reporting criteria established by the fb88 Department of Human Services and adapted in part from the "fb88 Septic System Inspection Guidelines" prepared by the fb88 Association of Site Evaluators. The information contained in this document accurately describes the conditions observed relative to the specific items referenced in this report that existed on the inspection date. No warranty is made or implied that the conditions described herein are representative of past conditions; will continue beyond the inspection date; or that the subsurface wastewater disposal system will function in compliance with the fb88 Subsurface Wastewater Disposal Rules. No inference can be made regarding the condition, status, or functionality of any system characteristic not specifically described in this report.`9No visible cracks or holes in observable portion of tank.2Scum & sludge occupy 1/3 or less of tank capacity.$Baffles are present and functional. $Adequate for the number of bedrooms.#Covers can be located and removed. 'Liquid level at or below outlet invert.4Separate electrical circuits exist for pump & alarm.*Float switches are present and functional.?No components visible; no trees or immovable objects on system.No malfunction per definition.'No visible evidence of surface erosion.<System meets setback on design plan or current rule minimum.MA record search was conducted, including owner, municipal, and state sources.>A record search was not conducted - reason noted in narrative.Not applicable to this item.(An external plumbing permit was located.WSystem was installed after June 1974 but external plumbing permit could not be located.(A certificate of inspection was located.XSystem was installed after June 1974 but certificate of inspection could not be located.7Septic tank pumping and/or system repair records exist.7Septic tank has not been pumped and/or system repaired.fCurrent owner has not pumped tank and/or repaired system; verification with prior owners not possible.6Property is served by metered public or private water.8Property is served by unmetered public or private water.,No internal plumbing exists on the property.HOwner and/or tenant have resided on property within the last six months.;Property has been vacant for previous six months or longer.:Unable to verify occupancy during the previous six months.$No structure exists on the property.*One or more garbage disposals are present.!No garbage disposals are present.JUnable to verify presence of garbage disposal - reason noted in narrative..One or more water treatment units are present.%No water treatment units are present.KUnable to verify presence of clothes washer(s) - reason noted in narrative.QUnable to verify presence of water treatment unit(s) - reason noted in narrative.OAll plumbing fixtures are physically connected to a subsurface disposal system.WUnable to verify the connection of all plumbing fixture(s) - reason noted in narrative.AOne or more plumbing connections for clothes washers are present.8No plumbing connections for clothes washers are present.eUnable to verify the condition of all water supplied plumbing fixture(s) - reason noted in narrative.SNo septic tank or aerobic treatment tank is present as part of the disposal system.dUnable to verify if a septic tank or aerobic treatment tank is present - reason stated in narrative.=Unable to observe treatment tank - reason noted in narrative.>Liquid volume is adequate for the current use of the property.BLiquid volume is not adequate for the current use of the property.JAccess cover cannot be located and/or removed - reason noted in narrative.!Liquid level above outlet invert.ESolids and/or scum occupy one-third or less of treatment tank volume.GSolids and/or scum occupy more than one-third of treatment tank volume.dUnable to verify if a grinder and/or effluent pump and tank is present - reason stated in narrative.SNo grinder and/or effluent pump and tank is present as part of the disposal system.BUnable to observe pump(s) and tank(s) - reason noted in narrative.ANo pump(s) or tank(s) are present as part of the disposal system.@Pump power and high water alarm circuits have separate breakers.=Pump power and high water alarm circuits have common breaker.NPump on, pump off, and high water alarm float switches present and functional.TPump on, pump off, and/or high water alarm float switches missing or not functional.bUnable to verify if a subsurface wastewater disposal area is present - reason stated in narrative.aA subsurface wastewater disposal area is not part of the waste disposal system for this property.jUnable to verify subsurface wastewater disposal area to water supply setback - reason stated in narrative.hUnable to verify subsurface wastewater disposal area to water body setback - reason stated in narrative.OBSERVATION &< EXPLANATIONiSystem was installed prior to June 1974; external plumbing permit could not be located and may not exist.jSystem was installed prior to June 1974; certificate of inspection could not be located and may not exist.fA review of the items relative to the internal plumbing was not completed - reason noted in narrative.FA review of the items relative to the internal plumbing was completed.eOne or more plumbing fixtures do not shut off properly and/or one or more faucets drip when shut off.TAll faucets close tightly without drips and all plumbing fixtures shut off properly.`Design plan specifies a subsurface wastewater disposal area; one is not present on the property.bGround surface on wastewater disposal area is stable, with no visible evidence of surface erosion._Design plan specifies grinder and/or effluent pump and tank; no pump(s) and tank(s) is present._All disposal system pipes and components are covered and surface area is clear of obstructions.dDisposal system pipe(s) and/or components are exposed; or surface area is not clear of obstructions.?Observable portions of treatment tank in serviceable condition.BObservable portions of treatment tank are deteriorated or cracked.BInlet and outlet baffles are present and in serviceable condition.JInlet and/or outlet baffle(s) are missing or not in serviceable condition.DObservable portions of pump(s) and tank(s) in serviceable condition.GObservable portions of pump(s) and tank(s) are deteriorated or cracked.Malfunctioning system: A system that is not operating or is not functioning properly. Indications of a malfunctioning system include, but are not limited to, any of the following: ponding or outbreak of waste water or septic tank effluent onto the surface of the ground; seepage of waste water or septic tank effluent into parts of buildings below ground; back-up of waste water into the building served that is not caused by a physical blockage of the internal plumbing; or contamination of nearby water wells or waterbodies/courses.UNKNNO****%Not normally applicable to this item.Malfunctioning system: A system that is not operating or is not functioning properly. Indications of a malfunctioning system include, but are not limited to, any of the following: ponding or outbreak of waste water or septic tank effluent onto the surface of the ground; seepage of waste water or septic tank effluent into parts of buildings below ground; back-up of waste water into the building served that is not caused by a physical blockage of the internal plumbing; or contamination of nearby water wells or waterbodies/courses.*Observed setback differs from design plan.aGround surface on wastewater disposal area not stable, with visible evidence of surface erosion.UNKN**M** - Listing of Specific Inspection Item System Deficiencies Noted on Page 3. OBSERVATION*0A system design plan (HHE-200 Form) was located.\System was installed prior to June 1974; design plan could not be located and may not exist.YSystem was installed after June 1974 but design plan (HHE-200 Form) could not be located.FOne or more fixtures discharge to the ground surface or an open ditch.GA septic tank or aerobic treatment tank is part of the disposal system.UA subsurface wastewater disposal area is part of the disposal system on the property.YSubsurface wastewater disposal area functioning per definition - no malfunction present.ZSubsurface wastewater disposal area not functioning per definition - malfunction present.]Observed disposal system to water supply setback(s) concur with design plan - (HHE-200 Form).bObserved disposal system to water supply setback(s) do not concur with design plan (HHE-200 Form).ZObserved disposal system to water body setback(s) concur with design plan (HHE -200 Form).`Observed disposal system to water body setback(s) do not concur with design plan (HHE-200 Form). Further Investigation Suggested:VSEE REVERSE SIDE OF THIS PAGE FOR GENERAL INFORMATION REGARDING THE INSPECTION PROCESSX* - Explanation of Observation Items Listed in Supplement to this Report Form (HHE-240).]Specific System Deficiencies Preprinted Items Represent Minimum Deficiency Conditions Established by DHS Checked Items Represent Deficiencies Identified During this Inspection ^ fDesign plan specifies a treatment tank; no septic tank or aerobic tank is part of the disposal system.INSPECTION ITEM (From Page 2) Disclaimer:3.g0Residential use: Risers undersized/nonexistant. 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