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HomeMy WebLinkAboutTitle V Inspection Report - 182 LACY STREET 3/21/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 182_Lam_Street _ Property Address Gre!.g,g_Von..qtqrnberg__. Owner Owner's Name information is required for every North Andover MA 01845 2-27-2018 page. CityfTown 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. Important:When RECEIVED filling out forms A. General Information on the computer, use only the tab 1 Inspector: MM� key to moveyour cursor-do not TOWN OF t�()IRIIA ANr)OVER use the return ..Bepj.amin-.C. Osgood, Jr. key. Name of Inspector none ren Company Name 157 Bluff Street Company Address ' n SalemNH 03079 City/Town State Zip Code 978-435-1324 870 Telephone Number License Number 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 6 (310 CMR 16.000). The system: H Passes Fj Conditionally Passes ❑ Fails El Needs Further Evaluation by the Local Approving Authority 4ro1 2-27-2018 Ins'p6cto r'seig n at u re 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 DER 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. (5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts t m Subsurface Sewage Disposal System Forme Not for Voluntary Assessments " r 182 Lacv Street Property Address Gregg Von Sternberg OwnerOwner's Name _. ____.._._..__.__ _..._...._..______..._.._.._�.............._..__..._...._w_.__.___..._. _.._.. information is Horth Andover MA 01845 2-27-2018 requiredfor every _..._----------------...............__..._..._..__........._.., _..__..._...._„.__,_..m._...___,.._.._,._.._ page. City/Town State 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 Fusses: ® 1 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: S) 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"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 structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass 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): ............ .._..............__-._..... t5ins+3113 Title 5 Official 9nspection Form;Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form an Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 182 lacy Street Property Address Owner Owner's Name information Is North Andover MA 01845 2-27-2018 required for every _ .....__._._._.__..� _......_.._ _..... __.._..._ ._._ page. CltyrFown 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): i ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N [l ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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: 3 ❑ 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 t5ins 3/13 Title 5 Officiai Inspection Form Subsurface Sewage Disposal System-Pape 3 of 17 Commonwealth of Massachusetts Title 5 Off"Icial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Lacy eut 1.82 Property Address GreggVOrr Sternberg -------- Owner Owner's Name information is required for every North Andover MA 01845 2-27-2018 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: El 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. F] 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. El 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 El 2 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 F1 0 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 EJ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/a day flow t5ins-3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Off"Idal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 182Lacy�Street ------- ---------- Property Address Greggn Sternberg Owner -------------- Owners Name information is required for every North Andover MA 01845 2-27-2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El 0 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. El 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El 0 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.] El 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 n E the system is within 400 feet of a surface drinking water supply El 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 11 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 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form b Not for Voluntary Assessments 182 Lacy Street Property Address Gregg Yon Sternberg_,,,_ ------------------...... Owner Owner's Name information is required for every North Andover MA 01845 2-27-2018 page. CitylTown 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 0 El 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? Z ❑ 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? El Z Were as built plans of the system obtained and examined? (if they were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? Z ❑ Were all system components, excluding the SAS, located on site? 0 El 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? Z 1:1 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: Z El Existing information. For example, a plan at the Board of Health. Z EJ 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: 5 5 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3113 Title 5 official frispection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forms Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Lacy Street _— .._...__.... _.._...._.-- _.... __-_ __..._.._ Property Address GreccVan Sternberg _. __.. _ Owner _— _.w.....____v...--- _ Owner's Name information ie North Andover MA 01845 2-27-2018 requiredfor every _.nw...._ __....-.,..----_._._ ..._.._.__. _.._...... ----- —_.._._....___ _w............_., ._ page. City/Town State Zip Code Date of Inspection D. System Information Description: 150_gallon septic tank, pump chamber, d-box, and infiltrator trenches 2 Number of current residents: _._.._..___.. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well Detail: Sump pump? R Yes ® No Last date of occupancy: current Date _......_..,. Commercial/Industrial Flow Conditions: Type of Establishment: _.........._.....___-- Design flow(based on 310 CMR 15.203): _._....._.._ _ .._..... __. GalBons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ........ - _._._..__.._..... 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: t5ins•3113 Title 5 Official Inspection Forfm Subsurface Sewage Disposal System•Page 7 of 17 i * A Commonwealth of Massachusetts Title 5 Offmcmal Inspection Form x f' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 182 Lagy._Street Property Address Gregg Von Sternbe__ _......... Owner Owner"s Name Information is North Andover NIA 01845 2-27-2018 required for every _ _...__.__ „ ...__.-- page, Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: [-ate __....._._._..._ _._........___._....._ Other(describe below): General Information Pumping (Records: Source of information: _Pumped approximately 3_years ac3o_per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: - ga116,ns 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) (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 DFP approval. ❑ Other(describe): pump chamber t5ins•3113 Title 5 official inspection Form:Subsurface Sewage Disposal System•page 8 of 17 Commonwealth of Massachusetts Totle 5 Offmcial Insped'on Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form mk 182 Lacy Street Property Address Gregg Von Sternberg Owner Owner's Name information is required for every North Andover MA 01845 2-27-2018 page. City/Town State Zip Code Date of Inspection D. -�iy-stem -Information (cont.) Approximate age of all components, date installed (if known) and source of information: �5er_B0.H,Appjqye�q Plan Were sewage odors detected when arriving at the site? [-1 Yes No Building Sewer(locate on site plan): 21 Depth below grade: feet Material of construction: cast iron El 40 PVC F! other(explain): Distance from private water supply well or suction line: > 25feet ' Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe OK in basement Septic Tank(locate on site plan): 1.5' Depth below grade: feet­­ Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1500 galloq§,___" 410 Sludge depth: t5ins-3118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 182 Lac Street Property Address Gregg_Von Sternberg ................... Owner Owner's Name information is North Andover MA 01845 2-27-2018 required for every .............. ........ page. 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 3011 ------ 411 Scum thickness Distance from top of scum to top of outlet tee or baffle 711 Distance from bottom of scum to bottom of outlet tee or baffle 1411 How were dimensions determined? Measure stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition, sch 40 pvc tees in good condition ........... ----------- Grease Trap(locate on site plan): Depth below grade: feet Material of construction: F1 concrete 0 metal n fiberglass Fj polyethylene F] 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: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 182 Lacy Street ----------- Property Address Gregg Von Sternberg Owner Owner's Name information is required for every North Andover MA 01845 2-27-20.18-1 page. CityTrown 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: El concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): ---------- Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: F Yes E) No Alarm level: Alarm in working order: El Yes El No Date of last pumping: Comments(condition of alarm and float switches, etc.): ----------- ----------- Attach copy of current pumping contract(required). Is copy attached? Yes ❑ No t5ins-3113 Title 5 Official Inspection Forin:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form '6 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18.2 acy Street Property Address Gre q_Won Ster berg n Owner Owner's Name information is North Andover MA 01845 2-27-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Oil 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.): Box in Qood condition. no evidence of solids carryover or leakage in or out. 2" below grade. Pump Chamber(locate on site plan): Pumps in working order: Yes n No" Alarms in working order: Yes R No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): gyTp chamber looks_qoqd,junctions normaRy ---——--------- 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: t6ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 182 Lacy Street Property Address 1 Gregg,Von-Sternberg_..._.__..._ ____.._.._ _._._.__. .. .. ........... _ _.__......_.., _ Owner .-.—_ Owner's Name information is North Andover MA 01845 2-27-2018 required for 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: 2 - 59.38" ❑ 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.): Leach field area vegetation looks very dry. 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 ___..._....._..__ -- i Materials of construction __...a,....-__-- __......_.. Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 4 y Commonwealth of Massachusetts . u _ A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Lacy Street Property Address Gregg Von Sternberg OwnerOwner's Name __.,. ... .._,.._._ ..,_..�_. ....__.__. . _...___...._ ___.._.�__......__ 1 information is North Andover MA 01845 2-27-2018 required far 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): Materials of construction: Dimensions _..._.___.._..__.._..._..._.._ _ -_- Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): I i t5ins•3113 Title 5 afficiat Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme Not for Voluntary Assessments 182 Lacy Street Property Address Gregg.Von Sternberg -—---- Owner Owner's Name information is required for every North Andover MA 01845 2-27-2018 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-T 4 A)0, /G. Z z 2-P A-) teal T Mae-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 182_Lacy Street ------- Property Address Gregg Vor� ternberq Owner Owner's Name j information is required for every North Andover MA 01845 2-27-2018 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water ❑ Check cellar Shallow wells Estimated depth to high ground water: 61 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: 04/2005 baie--- 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: U S G S.maps d inspector knowledge indicate water table> Commonwealth of Massachusetts Title 5 Offidal Inspection Form Subsurface Sewage Disposal System Form «Not for Voluntary Assessments r-Y P/ 182 Laq�Strqqt,_ Property Address Gregg Von Sternberg Owner Owners Name information is required for every North Andover MA 01845 2-27-201 page. State Zip Code Date of Inspection ................. E. Report ompleteness Checklist E 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 Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official ffispection Form Subsurface Sewage Disposal System-Page 17 of 17 X,�. Town of North Andover HEALTH DEPARTMENT �SSACWUS�'" CHECK ##: . ty.m. _ DATE: t H/0 NAME CONTRACTOR NAME: Tyve_of Permit or License: (Check box) • Animal $ • Body Art Establislnnent $ • Body Art Practitioner $ 0 Dempster $ 1 0Food Service-'Type:�mm��� $ Ci Funeral Directors $ ® Massage Establishment $ 0 Massage Practice 0 Offal(Septic)Hauler $ © Recreational Camp $ 0 Sun tanning $._...,. Swimming Pool $ 0 Tobacco $ 0 Trash/Solid"Baste Hauler $ 0 Well Construction $ SEPTIC Sterns: Q Septic-Sail Testing $ 0 Septic_Design approval $ IJ Septic Disposal Works Construction(DWC) $ t © Septic Disposal Works Insta tiers(DWI) $ © Title 5 Inspector $ Title 5 Depart $ ... 1 I El Other:(Indicate) $ Health"Agent Initials White-Applicant Yellow-Health Rink- Treasurer