901 1100 1101 1300 1301 1500 1501 1700 – – – – 1701 1900 1901 2100 > 2100 Unable to Determine – – Trench Size ft²; Totals: 100 300 301 500 501 700 701 900 – – – – 901 1100 1101 1300 1301 1500 1501 1700 – – – – 1701 1900 1901 2100 > 2100 Unable to Determine – – Probable Cause(s) of Failure; Totals: Septic Tank Failure Infrequent Tank Pumping Pipe Filled with Solids Damaged/Collapsed Hydraulic Overload System Undersized Piping System Insufficient Isolation Root Intrusion Installation to Water Table Unsuitable Fill Dirty Stone Excess Cover Lack of Maintenance Soil Clogging Unable to Determine Other: _____________________________________________________________________ DEQ Failed System Data Submission Form Residential – Calendar Year: Local Health Department: number of Residential failures: Dwelling Type; Totals:
901 – 1100 1101 – 1300 1301 – 1500 1501 – 1700 1701 – 1900 1901 – 2100 > 2100 Unable to Determine Trench Size ft²; Totals: 100 – 300 301 – 500 501 – 700 701 – 900 901 – 1100 1101 – 1300 1301 – 1500 1501 – 1700 1701 – 1900 1901 – 2100 > 2100 Unable to Determine Probable Cause(s) of Failure; Totals: Septic Tank Failure Infrequent Tank Pumping Pipe Filled with Solids Damaged/Collapsed Hydraulic Overload System Undersized Piping System Insufficient Isolation Root Intrusion Installation to Water Table Unsuitable Fill Dirty Stone Excess Cover Lack of Maintenance Soil Clogging Unable to Determine Other: _____________________________________________________________________ DEQ Failed System Data Submission Form – Residential Calendar Year: Local Health Department: number of Residential failures: Dwelling Type; Totals:
Onsite-Wastewater_Cycle-7_MPR-and-Indicator-Guide.docx