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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
5/30/17
Date of Inspection
001
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. —0
A. General Information
Inspector:
Mike Fisher
Name of Inspector
M.D. F. Septic
Company Name
P.O. Box 601
Company Address
-Rowley
Cityfrown
(603)401-6493
Telephone Number
B. Certification
MA
State
S113820
License Number
01969
Zip Code
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 15.000). The system:
E Passes El Conditionally Passes F� Fails
Needs Further Evaluation by the Local Approving Authority
W
, ad A%�/ -
Inbpector's Signature
5/30/17
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.
t5ins - 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I of 17
Owner
informati Is
required r
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover MA 01845 5/30/17
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:
1B) 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 Ej N El ND (Explain below):
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
L ..
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover MA 01845 5/30/17
Cityrrown 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
El Y
Fj N
El
ND (Explain below):
F1
obstruction is removed
El Y
El N
F]
ND (Explain below):
F1
distribution box is leveled or replaced
E] Y
F] N
[I
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):
F] broken pipe(s) are replaced El Y 0 N F ND (Explain below):
[I obstruction is removed Ej Y r-1 N F] ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El 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(l)(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
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
ELIE'
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover MA 01845 5/30/17
CityfTown 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:
Fj 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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
0 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 E Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El E Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
0 E Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
F, Z Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
0 E The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
F1 E 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 systerrithe system must serve a facility with a
design flow of 10,000 gpd to 16,000 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
Commonwealth of Massachusetts
Title 5
Official Inspection Form
the system is within 400 feet of a surface drinking water supply
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
El
285 Raleigh Tavern Lane
Property Address
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Susan Scott
Area — IWPA) or a mapped Zone 11 of a public water supply well
Owner
Owner's Name
information i's
required for
North Andover
MA 01845 5/30/17
every page.
Cityrrown
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
E:]
Z 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
Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El
Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
El
Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
D
0 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 pprn,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
0 E The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
F1 E 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 systerrithe system must serve a facility with a
design flow of 10,000 gpd to 16,000 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
El
El
the system is within 400 feet of a surface drinking water supply
El
El
the system is within 200 feet of a tributary to a surface drinking water supply
El
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.
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 Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner Owner's Name
information i's
required for North Andover MA 01845 5/30117
every page. City/Town 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?
N R
Has the system received normal flows in the previous two week period?
Ej 0
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)
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:
Existing information. For example, a plan at the Board of Health.
N E]
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): N/A Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: I 10 gpd x # of bedrooms): N/A
t5ins - 3/13 Tide 5 Official 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
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner Owner's Name
information i's
required for North Andover MA 01845 5/30/17
every page. CityrTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2 (Part7TTq
Does residence have a garbage grinder?
ED Yes
N
No
Is laundry on a separate sewage system? (Include laundry system inspection
F] Yes
N
No
information in this report.)
Laundry system inspected?
Yes
H
No
Seasonaluse?
El Yes
E
No
Water meter readings, if available (last 2 years usage (gpd)):
25 GPD
Detail:
Sump pump?
El Yes
N
No
Last date of occupancy:
Still Occupied
Date
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 F] No
Industrial waste holding tank present? F� Yes R No
Non -sanitary waste discharged to the Title 5 system? El Yes R No
Water meter readings, if available:
t5ins - 3/13 Title 5 Official Inspedon 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
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner
information is
required for
every page.
Owners Name
North Andover MA 01845 5/30/17
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Date
Source of information: Last 10 years ago, information from board of health
records
Was system pumped as part of the inspection? 0 Yes E No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
gallons
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
R Overflow cesspool
R Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Altemative 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):
t5ins - 3/13 Tito 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner Owner's Name
information is
renuired for North Andover
every page. Cityrrown
D. System Information (cont.)
5/30/17
State Zip Code Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Approximately 29 years old, information from plans
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 20 in.
feet
Material of construction:
0 cast iron El 40 PVC F-1 other (explain):
Distance from private water supply well or suction line: Town Water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete F� metal
14 in.
feet
0 fiberglass El polyethylene [:1 other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
Dimensions: 10 ft. by 5 ft. and 5 ft. deep
Sludge depth: 2 in.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
REM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner
information i's
required for
every page.
t5ins - 3/13
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Septic Tank (cont.)
RAA ^A^ -
Distance from top of sludge to bottom of outlet tee or baffle
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
5/30/17
Date of Inspection
36 in.
3 in.
7 in.
10 in.
How were dimensions determined? rulers and measuring rod
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 does not need to be pumped, inlet tee and outlet tee are in good condtion, liquid is at invert of
outlet pipe, no sign of leakage into or out of the tank.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
F� concrete F-1 metal
Dimensions:
Scum thickness
[:1 fiberglass
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:
feet
polyethylene E] other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner
information is
required for
every page.
Owner's Name
North Andover
Cityrrown
State
01845
Zip Code
5/30/17
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 0 metal El fiberglass El polyethylene [] other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
D Yes 0 No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
F� Yes R No
* Attach copy of current pumping contract (required). Is copy attached? El Yes [—] No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
5/30/17
Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
No Distribution Box
Pump Chamber (locate on site plan):
Pumps in working order: El Yes 0 No*
Alarms in working order: R Yes R 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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner Owner's Name
information is
required for North Andover
MA
01845 5/30/17
every page. Cityrrown
-�tate
Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits
number: 1, 8 ft. by 5 ft.
and 30 in. deep
leaching chambers
number:
El
leaching galleries
number:
El
leaching trenches
number, length:
El
leaching fields
number, dimensions:
overflow cesspool
number:
El
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.):
SAS contains 1, 8 ft. by 5 ft. leaching pit that is 30 in. deep. Pit is equal to 500 gal. and is 26 in. below
grade. Pit is dry. Dry gravel, no signs of hydraulic failure, no ponding.
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
0 Yes F-1 No
t5ins - 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover
MA 01845 5/30/17
Cityrrown 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.):
t5ins - 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
,p
Property Address
Susan Scott
Owner Owner's Name
information is
required for North Andover MA 01845 5/30/17
every page. Cityfrown -9-t-ate 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:
N hand -sketch in1he area below
El drawing attached separately
V i9
'3
.... ...... .. ...... .. ... .. 0-1
f77
'),3
t5irts - 3/13 Tift 5 Official Impection Form: Subsurface Sewage Disposal System - Page 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
Site Exam:
El
Check Slope
F�
Surface water
FJ
Check cellar
F]
Shallowwells
Estimated denthfn hi h rn"nrl wnfor-6
MA 01845 5130/17
State Zip Code Date of Inspection
94.4 in.
W W feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
If r-hor-L-otl t Info nf Hoci n Inn rinviouint-le
1988
I U F Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
El Checked with local excavators, installers - (attach documentation)
0 Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
from 99 Raleigh Tavern Lane (closest house at same elevation), no groundwater in TP 1 at 100 in.
and eshqw in TP1 at 94.4 in.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Owner
informati Is
required fo
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
285 Raleigh Tavern Lane
Property Address
Susan Scott
Owner's Name
North Andover MA 01845 5/30/17
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
M System information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
7907
Ani
Town of North Andover
HEALTH DEPARTMENT
AcHU
CHECK#: DATE: -,�0/7)
LOCATION: 5 wy-cm
H/O NAME:
CONTRACTOR NAME:
TyRe
of Permit or License: (Check box)
•
Animal
$
•
Body Art Establishment
•
Body Art Practitioner
$
0
Dumpster
$
•
Food Service - Type.
$
•
Funeral Directors
$
•
Massage Establishment
$
0
Massage Practice
$
•
Offal (Septic) Hauler
$
•
Recreational Camp
$
0
Sun tanning
$
•
Swimming Pool
$-
•
Tobacco
$
•
Trash/Solid Waste Hauler
$-
•
Well Construction
$
SEP77C Systems
* Septic - Soil Testing $
* Septic - Design Approval $
* Septic Disposal Works Construction (DWQ $
* Septic Disposal Works Installers (DW[) $
* Title 5 Inspector $—
xTitle 5 Report $570-
0 Other (Indicate)
Hen"ent Initials
White - Applicant Yellow - Health Pink - Treasurer