HomeMy WebLinkAbout- Title V Inspection Report - 394 BOSTON STREET 11/26/2018 C*mmonwealth of Massachusetts RECEIVED
- - Title Office l Inspection Form NOV '(? �
Sewage
stem Farm- Not for Voluntary Assessments � i',p
>; a Disposal �y
<, / f I i I i,iI
TMENT
Property Address r >
Owner Own blame
information is Jo(�required for every _ ✓ _._ _®_. _L �_
fA
page. City/Town State Zip Cade 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 A. Inspector Information
filling out forms /
on the computer,
use only he tab
key to move your Name of Inspector
cursor-do not t
use the return Company Name
key.
eti Comp ny A iress�
City—ter [ `.J j State . Zip Code
C�
Telephone Number License Number
B. rtif[cation
I certify that: I am a DEP approved system Inspector In full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system.-
1. asses
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4, Fails
Inspector's jn'atur Date
The sy 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: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.
tbinsp.doc-rev.7/26/2018 Tide 5 Official lnspecdon Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
c . Title 5 Official Inspection Form
..R
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4. b0:5
Property Address z
Owner 0 'S Name �5
inforrnation is fr
required for every
State Zip Code Date of Inspection
page. City/Town
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) em Passes:
71 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:
2) Syst Conditionally Passes:
one o ore system components as described in the "Conditional Pass" section need to be
replace r repaired, The system, upon completion of the replacement or repair, as approved by
the Board Health, will pass.
Check the box for s", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please lain.
The septic tank is metal d over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substant I Infiltration or exfiltration or tank failure is imminent, System will pass
inspection if the existing tank' replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspe ion if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is ss than 20 years old is available.
Y N El ND (Expla below):
'n
ND'S(E ss than 0 years old W,
pla below):
available.
e
h
In
p
e
e
0
replace
e
Boa
n Board 0
ore
rr 0
e
H
Co
nditionally p
y Health,
repaired.sy
stem t
e
m h
d
wi
ll
The m
h
11 e e p
no c
_k the box
for es '
determined,"
lease lain.
d 0
stant I I a t
se I ned,\Pn tank septic
t nk is met
�u nd, exhibits
sub
inspection
if t P,P
nn h existing
replaced
P'a'3'inspe �c tank is
t5insp.doc-rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Prop"Ass �
Owner er's Na
_ : � _ —
required J- -?-
information is
required for every State Zip Code Date of Inspection
page. Cityrrown
C. Inspection Summary (cont.)
2) stem Conditionally Passes (cant.):
❑ ump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
p ps/alarms are repaired.
❑ Observa' n of sewage backup or break out or high static water level in the distribution box due
to broken o obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspecti if(with approval of Board of Health):
�( broken p e(s)are replaced ❑ Y [I N ❑ ND (Explain below):
❑ obstruction is emoved E] Y ❑ N ❑ ND (Explain below):
❑ distribution box is veled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 ti qs a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of a Board of Health):
❑ broken pipe(s)are replaced Y ❑ N El ND (Explain below):
❑ obstruction is removed ❑ ❑ N ❑ ND (Explain below):
3) Further Evaluatiol' s Required by the Board of Health:
❑ Conditions exist wh h require further evaluation by the Board of Health in order to determine if
the system is failing t rotect public health, safety or the environment.
a. System will pass un s Board of Health determines In accordance with 310 CMR
15.303(1)(b)that the syste Is not functioning Ina manner which will protect public health,
safety and the environment.
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Off icial Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
t3o 7�sTcf�—:�) i
Property Addr s
to
Owner bw is Nam
information is nd o AE
required for every
page Cifyff6wn' State Zip Code Bate of Inspection
C. Inspection Summary (cont.) ,
Cesspool or privy is within 50 feet of a surface water
F1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. Syst will fall unless the Board of Health (and Public Water Supplier, If any)
determin that the system Is functioning In a manner that protects the public health,
safety and vironment:
7 The system as a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a su Ce water supply or tributary to a surface water supply.
El The system ha a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a eptic tank and SAS and the SAS is within 50 feet of a private water
supply well.
[I The system has a sep . tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water s ply well".
Method used to determine dis nce: µ --
This system passes if the well water a alysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no othe failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You Must Indicate "Yes" or"No"to each of the following for all Inspections:
Yes No
El Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
E] Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc rev,7/2612018 Tille,5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16
Commonwealth of Massachusetts
h Subsurface Sewage Disposal System Farm 4 Not for Voluntary Assessments
K� !
' = r
Property A ss
_ _
Owner
information is every
v - /
required for eve owner ame , { /`) � � t c , ►� 1
page. City own 4✓`� State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cant.)
Yes No
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
0) / Liquid depth in cesspool is less than 6" below invert or available volume is less
" El El than Y2 day flow
® Required pumping more than 4 times in the fast year 1VT'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.
El well.
portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ I� 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 certif led
laboratory,for fecal collform 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 2000 gpd-
El 10,000 gpd.
El criteria
system f ils. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
5) Large Systems: To be\eeed a large system the system must serve a facility with a
design flow of 10,000 g000 gpd.
For large systems, you mte either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the ' hin 400 feet of a surface drinking water supply
the withi 200 feet of a tributary to a surface drinking water supply
the locate in a nitrogen sensitive area (Interim Wellhead Proteotion
Are )or a ma ped Zone li of a public water supply well
t5msp.doc•rev.7126/2018 Title 5 0111dal Mspectlon Form:Subsurface Sewage Disposal System•Page 5 of 18
<e", Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Prop-artyAd r�Ss
r N 4C
Owner Owner" Name
information is
required for every
page -61ty-Pow n state Ce of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.6 the system is considered a significant
threat, or answered "yes"to any question in Section C.4 above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all Inspections:
Yes No
WEl Pumping information was provided by the owner, occupant, or Board of Health
E] V Were any of the system components pumped out in the previous two weeks?
yE] 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 Were as built plans of the system obtained and examined?(If they were no
available note as N/A)
❑ Was the facility or dwelling inspected for signs of sewage back up?
E] Was the site inspected for signs of break out?
0 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 Soli Absorption System(SAS) on the site has
been determined based on:
❑ 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
approximation of distance is unacceptable) [310 CMR 15,302(5)]
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Commonwealth of Massachusetts
OfficialTitle 5
� Subsurface Sewage Disposal System Norm Not for Voluntary Assessments j
`y
`-' Property Addre
Owner llrrs Na e
information Isrequired for every State Zip Code Dake of Inspection
page. ty own
D.
System Information
1. Residential Flow Conditions.
rooms (design): -- - Number of bedrooms (actual): '
Number of bed
DESIGN flow based on 310 CMR 15.203 (far example: 110 gpd x#of bedrooms):
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes eNo
Does residence have a water treatment unit? [l Yes No
If yes, discharges to;
Is laundry on a separate sewage system? (include laundry system inspection ® Yes No
information in this report.)
Laundry system inspected? �/'� El Yes ❑ No
Seasonal use? El Yes No
Water meter readings, if available(last 2 years usage (gpd)): w
Detail: �.. `�..�t I 'If
L u
Sump pump? Yes ❑ Now
Last date of occupancy: Date
t5inp,doc•rev.7120/2018 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
P
property Addre
Owner Ow, 's Name
information is P ) (' �a i!
required for every 7_718 - pd(� L 13-
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
2. ommercialAndustrial Flow Conditions:
Type Establishment.
Design flo based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design (seats/persons/sq.ft., etc.):
Grease trap present? D Yes Ej No
Water treatment unit presen 0 Yes 0 No
If yes, discharges to:
Industrial waste holding tank present? El Yes E] No
Non-sanitary waste discharged to the Title 5 stem? D Yes [I No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: one' r
Was system pumped as part of the inspection? D Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2612018 Title 5 Offirlal Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
T"tie 5 Off 1cial Inspection Form
Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
-- }} 'oz
L
Property Address'_'�
Owner t)e0,' N Ihm
i rM nfo ation is
required for every City
page. n State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
Septic tank, distribution box, soil absorption system
EJ Single cesspool
❑ Overflow cesspool
❑ Privy
El 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 DEP approval.
Other(describe):
Approximate age of all components, date installed (if known) and source of information:
L a,
Were sewage odors detected when arriving at the site? El Yes ETNo
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
t-least iron 40 PVC El other(explain):
Distance from private water supply well or suction line.
feet 1y)
Comments (on condition of joints, venting, evidence of leakage, etc.):
A ard C,
clil)-
t5insp.dGc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Taftle 5 Off icial Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Property Address
"
er"s —
r N.
information is s Y-2—TCS
Owner
required for every itvITO
ityrTown State Date of Inspection
page.
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
R'concrete 0,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 ❑ j No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness f
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
.Now were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
Ii uid levels as related to outlet invert, evidence of leakage, etc* '
I I
1 d' :�� - f- -
(2) -Q-...L4LC L
a 1
n ' hTr- w
(,-t ttrv- n(f)
15insp.doe•rev.7126=1 8 Title 5 Official Inspection Form Subsurface Sewage Disposal Systern-Page 10 of 16
Commonwealth of Massachusetts
Title 5 Off 01cial Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
20
Property Address
Ct
:f'L
----------- -------
Owner er's 7�
information Is NA" 00-v's
required for every State Zip Code Date of Inspection
page, pityrrom
D. System Information (cont.)
7. ease Trap (locate on site plan):
Dept elow grade: feet
ease
'Trap
(locate
Depth
th elow grade:
Material of nstruction:
E 0 E
3 concrete metal El fiberglass polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of tlet tee or baffle
Distance from bottom of scum to bottom f outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inle nd outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence o akage, etc.):
8. Tight or Hold Tank(tank must be pumped at time of inspection) (10 ate on site plan):
Tank must be
Depth below grade:
Material of construction:
0
D concrete El metal El fiberglass polyethylene El other(explain):
Dimensions:
Capacity: gallons
Design Flow: g ons per day
t51nsp.doc-rev.7/26/2018 Tl0.5 Official ln.v..,lcm m:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Off fficial Inspection Form
Not for Voluntary Assessments
Sewage Disposal System Form
Subsurface
in
Property Address
Owner rws Name
information is
required for every Date of Inspection
C tyIT6W
page. n state Zip Code
D. System Information (cont.)
8. Tig or Holding Tank (cont.)
Alarm pr nt: ❑ Yes El No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping.
Comments (condition of ai and float switches, etc.):
Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
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.):
no
Q
t5insp.doc-rev.7126/2018 Title 5 Official inspection Form Subsurface sewage Disposal system-Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form d Not for Voluntary Assessments
A
Property Address.,
'S /9
Owner inforrnation is OW S�ame _g)
required for every State page. —ityrrown
D. ystem Information (cont.)
10. PUMP lumber(locate on site plan):
Pumps in wo ing order: C! Yes No*
Alarms in working der: El Yes El No*
Comments (note conditi of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, syste is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
EJ leaching pits number:
El leaching chambers number:
El leaching galleries number: LL
0 leaching trenches number, length:
El leaching fields number, dimensions:
❑ overflow cesspool number:
El innovative/alternative system
Type/name of technology.
15insp,doo-rev.712612018 Title 6 Official Inspection Form:Subsurface Sewage DiSP0881 System Page 13 of 16
Commonwealth of Massachusetts
p Title 5 Off 81cial Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
aa
570 4-Property Addre,s�
7_
Owner 017' Nam, Pj\
Information Is A 6
required for every
page. City/Town State m Zip Cade bate of Inspec#ian
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.)-.,
C G loc�
VA?
12. sspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number configuration CI
Depth— 0 top of liq to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes No
Comments(note condition of soil, signs of hydraulic failu level of ponding, condition of vegetation,
etc.)-.
15hap.doc rev.7126/2018 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal SYslem-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address_f�—,
;
0 r" -j4a—
Owner rif I
information is —( --��-�t P 1
required for every
page. C—ity/Town State Zip Code Date of Inspection
System nformation (cont.)
13. Privy ate on site plan):
Materials of co ruction*
Dimensions
Depth of solids
Comments (note condition of soil, si of hydraulic failure, level of ponding, condition of vegetation,
etc.):
f5insp.cloc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
�. Commonwealth of Massachusetts
Title 5 Official Inspection Form
_.
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
rt�: Property Address
information
Nainformation is —required for every State dip Code gapageper's
Town
D. System Information (cant.)
14, Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two.permarient 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
f
J-
i
l
A cI
X
L
t51nsp.doc rev.712012018 Title 5 official inspection Form:Subsurface Sewage Disposal System Page 16 of 18
Commonwealth of Massachusetts
Title 5 Off fflicial Inspection Form
Subsurface Sewage Disposal System Form® Not for Voluntary Assessments
Property Address
,
Owner 0 Nama/A
Information Is 77 Rl"I dI n a
required for every ri&
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
check Slope
M/Surface water
D/Check cellar
o/shallow wells
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
If checked, date of design plan reviewed:
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)
El Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
QA- r*S' 10 A D
rO be
(06f,fi"Int, -FwJ d
f) 1 SnX
Before filing this Inspection Report, pleases Report Completeness Checklist on next page.
t5insp.doo rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Y �L
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
PropertyAddre
Owner O ers No
Information Isrndrequired for every �Uiu
�--T
page. City/Town State Zip Code Gate of Inspection
E. Report Completeness Checklist
i
Complete all applicable sections of this form Inclusive of:
I.B--'A• Inspector Information: Complete all fields in this section.
[�KB. Certification: Signed & Dated and 1, 2„ 3, or checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
lDD• System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 16: Explanation of estimated depth to high groundwater included
t5insp.doo•rev.7126/2018 Title 5 pHkclal Inspection Form.subsurface Sewage Disposal System•Page 18 of 18
N,ORTW 5 i «,
Town of North Andover
"•";, a': HEALTH DEPARTMENT
paSASNUStt
HRCK# DATE: ^
LOCATION: kv
H/O NAME:
"..
CONTRACTOR NAME
Type of Permit or License:ense: (Check box)
0 Animal $
❑ Body Art Establishment
❑ Body Art Practitioner $
❑ Dumpster $ _
❑ Food Service-Type:___._ —_ $
❑ Funeral Directors $ _
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler
❑ Recreational Camp
❑ Sun tanning $_
❑ Swimming Pool $
❑ Tobacco $_
❑ TrasIVSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
Septic-Soil Testing
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5Inspector $
Title 5 Report „ $
(I�
1
❑ Other:(Indicate).._.— $
llealth,Ajent Initial
WM to-Applicant Yellow-Health Pink-Treasurer
z�z
S60zM 66