HomeMy WebLinkAboutTitle V Inspection Report - 257 BOXFORD STREET 4/17/2018 Commonwealth of Massachusetts
Title 5 Official Inspection ForM RECEIVED
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
7 ZU
APR "1 3
257 Boxford St.
1oWt+OF NORU-1
Property Address HEALTH DUARTMEW
Holland
OwnerOwners Name
information is
required for every North Andover Ma 01845 4/11/2018
page. City/Town 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:WhenA
filling out forms A. General illformatl®n
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Jablonski
use the return
key. Name of Inspector
C.J. Jablonski Septic Inspection and Repair
VQ Company Name .........
237 Merrimac St.
Company Address
yearn Newbur port MA 01950
City/Town State Zip Code
978-360-9358 4574
IT69
6l p h one 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 5 (310 CMR 16.000). The system:
El Passes ❑ Conditionally Passes Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspectors
tiginfatur Date
The system in ector shall submit a copy of this inspection report to the Approving Authority(Board
Sys 't
P)
of Health orP) 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.
t5ins-3193 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
257 Boxford St.
---------- -----_----
Property Address
Holland
Owner bwne"r`"s N-ame
information is
required for every North Andover Ma 01845 4/11/2018
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 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:
13) System Conditionally Passes:
El 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.
El Y F] N El ND (Explain below):
................
t5ins-3113 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
257 Boxford St.
Property Address
Holland
Owner Owners Name
information is
North Andover Ma 01845 4/11/2018
required for every ------- — --
page. dtyfTown State Zip Code Date of Inspection
B. Certification (cont.)
F-1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
El 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):
F-1 broken pipe(s) are replaced 0 Y El N F1 ND (Explain below):
El obstruction is removed E] Y 0 N F-1 ND (Explain below):
❑ distribution box is leveled or replaced E] Y E] N El ND (Explain below):
-------.....
.............
F1 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 F1 Y 0 N F ND (Explain below):
❑ obstruction is removed El Y F-1 N F 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:
F] Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
TitleI 1Inspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
257 Boxford St.
Property Address
_Holland
Owner Owner's Name t
information is North Andover Ma 01845 4/11/2018
required for every _.._.... .... — _. _..__ _
Page Cltyfrown 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.
F] 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:
** 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
® 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 '/2 day flow
15ins-3113 T Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
I
Commonwealth of Massachusetts
WTitle 5 Official
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
-,-�� 257 Boxford S#.
Property Address
Holland
Owner ---_- - ..-.___. .. . . _.__.__—.__.._ .._.._._ __....... .,......_._—......... _.._.
Owner`s Name
information is North Andover Ma 01845 4/11/2018
required for every _. w_....___ __.... _....._..— ._...__.
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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.
❑ ® 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.
t5ins-3113 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 A Not for Voluntary Assessments
257 Boxford St.
Property Address
Holland
Owner _..._.., , .___ __..._..........._..._ _.....----- _....._. ._... _. _.._.._._. ...__.._-., .._..._
pwner"s Name
information is North Andover Ma 01845 4/11/2018
required for every
page. Cityrrown 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
El 0 Were any of the system components pumped out in the previous two weeks?
M n Has the system received normal flows in the previous two week period?
El M 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)
El Was the facility or dwelling inspected for signs of sewage back up?
• El Was the site inspected for signs of break out?
• F] Were all system components, excluding the SAS, located on site?
• 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?
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:
M EJ 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
El H approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
4
Number of bedrooms(design): — Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins-3/13 Title 5 Officlai Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
257 Boxford St.
Property Address
Holland
Owner Owner's Name
information is North Andover Ma 01845 4111/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
—------------ .......
Number of current residents:
Does residence have a garbage grinder? El Yes M No
Is laundry on a separate sewage system? (include laundry system inspection M Yes M No
information in this report.)
Laundry system inspected? 0 Yes E] No
Seasonal use? 0 Yes E No
Water meter readings, if available (last 2 years usage (gpd)): Private Welll
Detail:
..............
Sump pump? ❑ Yes No
Last date of occupancy: 4/2018
Commercial/industrial Flow Conditions:
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? El Yes Ej No
Industrial waste holding tank present? n Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
257 Boxford St.
-------------
Property Address
Holland
Owner .__..._.__. __._ _...__ .....__. _.__._.._ . ._ r_......_ _._._., ..._.__..._..__
Clwner's Name
information is North Andover Ma 01845 4/11/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other(describe below):
.................
General Information
Pumping Records:
Source of information: Home Owner
Was system pumped as part of the inspection? El Yes M No
If yes, volume pumped: na
gallons
How was quantity pumped determined? na
Reason for pumping: na
Type of System:
Septic tank, distribution box, soil absorption system
Single cesspool
El Overflow cesspool
11 Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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
EJ Tight tank, Attach a copy of the DEP approval.
El Other(describe):
thins-9113 Title 5 Official lnspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
-----------
x.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
257 Boxford St.
Property Address
Holland
Owner Owner's Name
information is North Andover Ma 01845 4/11/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Permit dated 3/1990
-----------
Were sewage odors detected when arriving at the site? El Yes EJ Na
Building Sewer(locate on site plan):
54"
Depth below grade: eet from top foundation
Material of construction:
El cast iron ED 40 PVC El other(explain):
Distance from private water supply well or suction line: na
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Watertight at foundation
............
Septic Tank(locate on site plan):
2411
Depth below grade: feet
Material of construction:
Z concrete F] metal El fiberglass ❑ polyethylene ❑ other(explain)
..........
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes n No
1500
Dimensions:
3"
Sludge depth: -
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official i
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.• ¢ 257 Boxford St.
Property Address
Holland
.._.... __._...._-.. _ ......._...._.--
Owner Owner's Name
information is North Andover Ma 01845 4/11/2018
required for every --:....-..._ �...._ _..._... _ �...__..... _. ............__ _..,,, ........
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.) f
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 31"— ----.._._.... _-- -..
1"
Scum thickness ___._..... __._......__ _
5°
Distance from top of scum to top of outlet tee or baffle ------ __._ .....
"
14
Distance from bottom of scum to bottom of outlet tee or baffle 141
How were dimensions determined? measuring tape
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 was structurally sound. Inlet and outlet tee's were in good working order.
Grease Trap(locate on site plan):
Depth below grade: feet _
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
__._....._._._---
ate of lastpumping: Date
t5ins 3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Officulal Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
257 Boxford St.
Property Address
Holland
Owner Owner's Name
information is North Andover Ma 01845 4/11/2018
required for every -------------- --
page. City/Town 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 F] metal El fiberglass El polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: _... __.. ._ _.......
gallons per day
Alarm present: El Yes El No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? n Yes Fj No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
-r- 257 Boxford St.
Property Address
Holland
OwnerOwners Name
information is North Andover Ma 01845 4/11/2018
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):
Depth of liquid level above outlet invert 3/411
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.):
Liquid level in box was high due to hydraulic failure.
Pump Chamber(locate on site plan):
Pumps in working order: F] Yes n No*
Alarms in working order: El Yes F-1 No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Sol[Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
--------------
----------
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
<C�\ Commonwealth of Massachusetts
T OIL
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
257 Boxford St.
Property Address
Holland
Owner Owner's
..__.._. __._._.__ __. ...... .. ......__ __.__...._ _....__ .._w___.
Owner's Name
information is
required for every North AndoverMa 01845 4/11/2018
page. CitytT'awn State Zip Cade Date of Inspection
D. System Information (cant.)
Type:
❑ leaching pits number: _,.,_...___ .. ....
❑ leaching chambers number: -
❑ leaching galleries number: -._......_._
® leaching trenches number, length: 2-54'._._._ _..... .._.._
❑ 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.).
Trenches are in hydraulic failure. System is still functional but does meet minimum criteria to pass.
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
Materials of construction ..__..._._.......___ _......__
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 1itle 5 OfricW Inspection Form:Subsurface Sewage Disposal System Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
257 Boxford St.
Property Address
Holland
Owner Owner's Name
information is North Andover Ma 01845 4/11/2018
required 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):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t6ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
? Title 5 Officual Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
257 Boxford St.
-------------------- .............
Property Address
Holland
Owner Owner's Name
information is North Andover Ma 01845 4/11/2018
required for every
page. bit-Wroi n_ 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:
0 hand-sketch in the area below
El drawing attached separately
W
N o C3 I
(D
C_
fa
C,
t5ins-3/13 Title 5 Official trispection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title i iInspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
257 Boxford St.
Property Address
1,
Holland
Owner Owner's Name
information is North Andover Ma 01845 4/11/2018
required for every _.._ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) I
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
84"
Estimated depth to high ground water: feet ..,-..-- —._........_—
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
3/1990
If checked, date of design plan reviewed: atei-
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:
Soils test performed Marcicionda before house was built
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Rage 16 of 17
Commonwealth of Massachusetts
rTitle 5 UTTIcial
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`Y 257 Boxford St
Property Address
Holland
Owner Owner's Name
information is North Andover Ma 01845 4/11/2418
required for every
page, CityfFown State Zip Code Date of Inspection
E. Report Completeness Checklist
Z 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
thins,3/18 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Pape 17 of 17
4,
Town of North Andover
HEALTH DEPARTMENT
CHECK DATE:
LOCATION:
H/O NAME: .---. gy 04"Y
CONTRACTOR NAME:
Tape of Permit or License: (Check box)
• Animal $
• Body Art Establishment $
• Body Art Practitioner $
0 Dunipster
0 Food Service-Type:,
-
0 Funeral Direct or,i $
0 Massage Establishment
0 Massage Practice
0 Offal(Septic)Hauler
0 Recreational Camp
0 Sun tanning $
El Swimming Pool
0 Tobacco $
0 Trash,/Solid Waste Hauler $
0 Well Construction $
SEPTIC.Systetras:
0 Septic-Soil Testing $
0 Septic-Design Approval
0 Septic Disposal Works Constriction(DWQ $
0 Septic Disposal Works Installers(DM) $
0 Title 5 Inspector $
Title 5 Report $
.................
0 Other: (Indicate) $
Hea thAgent Initials
White-Applicant Yellow-Health Pink-Treasurer