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HomeMy WebLinkAboutPass - Title V Inspection Report - 191 HAY MEADOW ROAD 7/9/2019 x Commonwealth oflWassachusetts * T ti e 5 0 Icial " "IP Subsurface Sewage [deposal System Form Not for Voluntary Assessments t +I�ry rO +I 114 Property Address ' I N q I FLAP l r ' nfo nnation is .,,,7__j '[,(/ required for eves A��O page. it T vm ,Mate Zip Code Date of Inspection Inspection results rnust be submitted on this form. Inspection forms;may not be alteredin any way.Please see completeness checklist llsf at,the end of the form. Important:When . Insopmetor Information filling out forms *W 1,1/1 on the computer, (�-,A�,,e, a + the to )t ( I key to move your Name of Inspector cursor-do not use the returnC l' �. m 4._._. kip CO r a, Address n ?RF° F �rovvn Telephone'Number License Number B., Certification I certify that., I am,as DEP approved system inspector in Ball compliance with Section 15.3,40 of Title (310 AMR d - ; l have personally inspected the sewage is s I system at the r pert address I ated above4 the information reported below is true, accurate and complete as of the time of my inspe ti w and the inspection was performed base 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: I. passes, 2. Ej Conditionally passes 3. El Needs Further Evaluation by the Lori Approving Authority 4. El Fails I Cl/ t mom. 4Signr pectoris Date i The:system inspector shall sub ` a.copy of this'Inspection�tir report to, Approving Authority('Board of Health or DEP within 30 days of completing this inspection. If the system has a design flow of 1, , pld or greater,the inspector and the system owner,shall submit the report to the ppr+oplri at r regional office of the DER The original form should be sent to the'~system owner and copies seat t the uyer, if applicable,and the approving authority. Please note,:This report onl describes difi s at the time If Inspection and under the conditions, wf use at that fly .This,inspection does not address,how the system will perform r In the future under the same or different conditions,of use. t5in pAOC.M.712612018 Me 5 OfficialInspection Pow:Subsurface Sewage Disposal System-Page i f 1 I Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments, Property Address ko Owner Owner's Nanj,j CNI inn ormafion is 11 1%4 %P`N%Nk,, required,for every (ef q,,� page. CityrTown State Zip Code Date of Inspection C. Inspection Summary, I nspection Summary.-Complete 112, 3,,or 5 and all of 4 and 6'r 1) System Passes: I have not found any information which ind,icates that,any of the fallure criteria described in,310 CMR 15.303 or in 310 Wk 6.3 exist.Any failure criteria not evaluated are indicated below. Comments, Aj 2) System Conditionally Passes: El One or more system,components as,descri"bed 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 s Ubastantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exisfir4tq k is replaced with a complying septic tank as approved by the Board of Health., A metal septic tank will pass ins cl,tion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is)ess than 20,years old is available. El Y N E:1 ND(Explain Wnsp.doc-rev.7126r2016 Title 6,Offidat Inspedion.Foffn,Subsurface Sewage Disposal!System Page 2 of 1.8 Commonwealth ssachuseft cu nctionia > Subsurface Sewage Disposal System Form Not for Voluntary Assessments �Y Property Address L ,Owner Ownefs,Na information is Z" required for every page. CitylTown State Zip Code Date of Inspection C., Inspection SUM (cont.) 2) System Conditionally Passes (cont.): E] Pump Chamber pumps/alarms,not operational.System will pass with Board of Health approval if errps/a,larTns are repaired. El Observation sewage backup or break,out or high static water level in the distribution box due to broken or obstructbd,pipe(s)or due to a broken,, settled or uneven distribution box. System will i pass inspection if(with,�'�prqval,of Board of Health): broken pipe(s)are rep] 8" 0 Y [:1 [j ND(Explain,below). obstructionis removed ININS Y N Ej ND(Explain below): INN El distribution box is leveled or replaced E] �s� El N 0 ND(Explain below).- The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system n will pass inspectio if(with approval of the Board of Health): .......0 ........ roken,pipe(s)are replaced 0 Y N El ND(Explain below): AA 0 obstruction,is removed Y N E] N,D(Explain below), maN 3) Further Evaluation is Required by the Board of Healt, .............. El Conditions exist which require further evaluation by the Board,of Heal'ith in order to dietermi neif the system is failing to,protect public health,safety or the envirorirnent. a. System will pass untess Board of Health determ roes in accordance with 310 CMR 16.303(l)(b)that the system is not functioning in a manner whic�h,will protect public health, safety and the environment: Mnsp.doc rev.7/26/2018 'n,Ue 5 Offidal Ire spedon Fon-n-1 Subsurface Sewage Disposal System-Page 3 of 18, Commonwealth of Massachusetts Title 5 0ifficial Inspection For Subsurface Sewage Disposal System Form Not,for Voluntary Assessments o Property Address Oym!er Ownees,Nam, information is required for every page. fit own state Zip Code Date of Inspection C. Inspection Summary (cont.) Q 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 b. System'will fai"I unless the Board of Health (and Public Water Supplier, if any) determines that,the system is functionIng "in a manner that protects the plublic:health, safety and environment: the system has a s6pt(p 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. E] The system has a septic tank and SAS and the SAS is within a Zone I of a Public water supply. The system has a septic tank and Sa,nd the SAS is within 50 feet of a private water supply Well. The system has a septic tank and SAS and the"N 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 it the well water analysis, performed at a DEP certified laboratory, for ll coliform bacteria indicates,absen't,and the presence,of ammonia nitrogen and nitrate nitrogen is equal to or less,thian 5 ppm, provided tar o other 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 alllns ctions: 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 Wnsp.d oc-rev.7/2MO 18 Me 5 OffidW,Inspecton Form-Subsufface, Sewage Disposal,System-,Page 4 of 18 N- e 1 uommonwealth, of Massachuseft T JM&I X% AM'so. utficial �� ixiiw 5 tion Fors. Subsurface Sewage Disposal System Form Not for Voluntary Assess eats Property address e k Owner �. information is OT, 7; "`� CA/ Al required for eves f page dIty'IToVm State Zip Code Date of Inspection C. Inspection Summary (cont) Systems Failure Criteria A lla a l to All Systems:(cont.) Yes N Static liquid lee l ire the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool IJ Liquid depths in cesspool is less than 6"below invert or available lam is less than 1/2day flaw E] Required pumping more than 4 times in the last year NOT due to clogged or obstructed i 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 1 " r tributary to a surface water supply. E] Any portion of a cesspool or privy is within a Zone 1, of a public water supply well. El Any portion of a cesspool l r privy is within 60 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 private water supply well witha n accept able water ualiit an l sis. [This system passes if the well water analysis, performed at a DEPcertified d lab ra,t r ,,for fecal coliform bacteria indicates as sent and the presence f ammonia nitrogen and nitrate nitrogen is equal to or:less than 6 ppm, provided that no other f atlu re criteria are triggered.A copy of the analysis and ha iry of custody mast be attached to this form El The system is a cesspool serving a facility with a design flour of 2000 gpd- 10,000 gpd. The sEl .............. ystem fails.l have determined that one r more of the above failure, criteria exist as described d in 310 CMR,15.303,therefore the systems falls.'The system owner should ld mat the Board of Health to,determine ine wh at will be necessary to correct the failure. 6 Large Systems- To be considereda largesystem the system must serve a,facility with a do's wu 1 flow f I , � t . 5�0 gpd. For I" ta"arge,,systems, you mustindicate either y 31 .„ "to each of the following, in addition to the questions,ir.......Sec ti n C.4,. Yes No :. the system is With rr 400 feet of a surface pp drip ire , titer supply � r the stem is within 200 i6etjqf a tributary to a surface d�rihking water supply E3 11 the system is located in a nitre , gnsitiv area(Interim Welly d'Protectio Area 1'W "A or mapped d Zone 11 t"b,,p li �water pp"lI well ll Tam 5 Offid l In on Faun:Sub u Sewsgie Disposal System.Page of 18 .. Commonwealth of Massachusetts T"Itle 5 Official Inspection For Subsurface Sewage Disposal System F -blot for Voluntary Assessments Property Address Owner Owners "'am,eAlIl., infoFmation is 41 required for eve�ry page. Cityrrown S ate- 'Zip Code Date of Inspection' C. Inspection Summary (cont,.) If you have answered"yes"to any,question in Section,C-5 the system is considered a significant threat,or answered "yes"to any question in Section C. 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 inaccordance,with 310 CAR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must"In4icate"'Yes"or"no"for each of the following for all"inspections,., Yes No Pumping information was provided by the owner,, occupant, or Board of'Health E] Were any of the system components pumped out in the previous two weeks,?. Has the system received normal flows in the previous two week period? Ej Have large volu mes 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 a flable note as N/A) val Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were a,]]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 slWge and depth of scum? Was the facility owner(and occupants if different from owner);provided with information on the proper maintenance o,f subsurface sewage isp,osal systems? The size and tocation 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. Ei Determined in the field(if any of the failure criteria related to Part C is at issue 1 approximation of d1*stanze is unacceptable)[3110 Cl IR 15,3 5)] t6insp.doc-rear.7126t2018 'n Ue 5 Offid al I nspedon Form:Subsurface sewage oi spo sai system-page 6 Of 1 a y. Commonwealth of Massachusetts, 1%ection Form "tie cial Ins* 1 5 , SubsurfaceSewage Disposal System Form, Not for Voluntary Assessments Property Address Owner Owner's information is required for every Fags. City[Town, State Zip Code Date of inspection D. System, Information 1. Residential to Conditions: Number of bedrooms(desilgn).@ Number of bedrooms(actual): DESIGN flow based on 31 10 CM 15.203(for example: 110 gpd x#of'bedrooms Description: 3 Number,of current residents: Does residence,have a garbage grinder? 0 Yes No, Does residence have a water treatment unit? Eli Yes No If yes,discharges to: Is laundry on a separate sewage system?,(Include laundry system inspection El Yes No information in this,report.) Laundry system inspected? Ej Yes No Seasonal use? Ej Yes b No Wat r meter readings I If available(last 2 years usage(gpd)): Detail.- Sump plump? 0 Yes, No Last date of occupancy: 0, Lk wfj e Date t5insp.doc-rev.7126/2018 Me 5 Offidial Inspedon Floe:Subsurface Sewage Oispo sal System-Page 7 of 18 Commonwealth of Massachusefts T itle 5 Official Inspection For Subsurface Sewage D11'sposial System Fonn -Not for Voluntary Assessments Property Address Owner Owner's N information is req u i red for lever' page. City/Town Ptaie'_ Zip Code Date of lnsp�c�tion D, System, Information (cont.) 2. Com merd'a Iliad ustr1alF low Condifions.: "Type of Establishment Design flow(based on 310 CMR 151.203): Gallons per day(gpd) Basis of design flow(sealts/persons/sclft,etc.): Grease l trap present?. Yes No Water treatment unit present'?, El Yes No If yes,discharges to: I ndustrial waste holding tank present? El Yes [:1 No Non-sanitary waste,discharged to the Title 5 system? Yes M to i , Water meter readings,, if available: Nry Last date of occupanGyluse: Date Other(describe below): 16, t 3. Pumping Records: Source of information.- Was system pumped as part of the inspection? El Yes No If yes, volume pumped.1- gallons How was quantity pumped determined? Reason for pumping: t6i nsp.duo rev.7/26/2018 Me 5 Official Inspection Form,Subsurface Sewage Disposal SysteM,-,Page 8 of 1,8 ("A"cimmonwealth of Massa,chusetts, Title 5 Official Inspection For > SubsurfaceSewage Disposal System,For Not for Voluntary Assessments, PIrk Address Owner, Owners Nftift information is required for every page. it own 6 Zip Code Date of Iris pection D, System Information (cont.) 4. Type,of System: All Septic tank, distribution box,wil absorption system El Single cesspool 0 Overflow cesspool 0 Privy IP1111., Shared system (yes oCno if yes,I attach previous inspection records,if any) El Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to ble,obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract El Tight tank.Attach a copy of the roval., E) Other(describe): Approximate age of all components,date installed it known)and source of information'. Ar)z?Art, o If T" Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer(locate on site plan): Depth below grade: Met Material of construction: Cast iron [J 40 PVC other(explain)-. Distance from private water supply well or suction line:: feet Comments(on i ,condition of joints, venting, evdence of leakage,etc.).- A-) t5ln sp.doc rev.'7126/201 8 Tifle 5 Offidal Inspecdon Fonn:Subsurface Sewage Disposal System Page 9 of 18 ti Commonwealth of Massachuseft T"tle 5 Official, Inspection For Subsurface Sewage Disposal Syst m Form Not for Voluntary Assessments, 44" Property Address Owner Owner's Na a,.......... inform,ation is „AIM J Ys A 13, req u i red fo r every it page., it own State Zip Code Date of Inspection' D, System, Information (cont.) 6. Septic Tank(locate on site plan)- Dept below grade'. feet Material of construction'. Rconcrete El miet l [:1 fiberglass [:3 polyethylene El other(explain) If tank is metal, list age: years Is age of by a Certificate of Compliance?(attach,a copy of certificate) 0 Yes D No Dimensions*. Slud'ge depth: Distance from top of sludge to,bottorn of outlet tee or of Scum thickness III Distance,from top of scum to top of,outlet tee or of Distance from bottoms of scum to bottom of outlet tee,or baffle 2 oA How were,dimensions determined? U Comments(on pumping recommendations,, inlet and outlet tee or baffle condition,structural integrity,, liquid levels as,related to outlet invert, evidence of Ileakage,etc.):, tit Ciep, .......... WIIII tr" "semn iNA tl a. ........ 1,51 nsp.doa rev.7126/2018 Me 5 Offida,l Inspeefion Form,Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachuseft M_ Title 5 Official Inspection Form Not for Voluntary Assessments > Subsurface Sewage D'isposal System Form rrty,Address Owner ergs, ;w �� � information required for every page. City State Zip Code Date of Inspection D. System; Information (coat.) 7. 'o%,Grease Trap(locate on site plan): Depth [ w,,,, feet Materi ul oaf construction. El concrete met l �'�°�� fiberglass polyethylene other expl inn Sc urn thickness ness -"bis ry sacs from top of scum to top of outlet fee or baffle �W w Distance from, ,,bottom of scum to bottom of outlet tee or baffle Date f lastpumping,: �, Date Comments �n urri 'inn recommendation����,Jnl ,"arid outlet tee r baffle cnridition,, structural in+ not , liquid levels as related to outlet invert,evidence of"Iea g , etc.). �. Tight or Holding Tank(tank must be pumped at time ofinspection)(locate n site plea).. .....Depth below grad . Material f"" n1struction, concrete metal El,fiberglass pol etl l n+ offer(explain): u9 n shone 1 Design Flow: gallons per day. t5l'nsp.doc rev..712 1 'nue 5 mw inspection For,subsurface Sewagae„'is�po i System-Fags 11 18 Commonwealth of Massachusetts IL q 5 unicial Inspection For Subsurface Sewage,Disposal System For Not for'Vo lure tary Assessments Property Address e Owner Owners information is required for every as page. City[Town. state Zip,Code Date of Inspection D. System Information (cont.) 8. Tight or Hold"Ing Tank(cont.) .............1 ,Alarm osrrt F1 Yes D No Alar m level-, AN Alarm in working,order- El Yes El No Date `............. t Comments(condition of al an in and float swit ls,,,etc.), ......... .......... ti MN Attach copy of current pumping contract(required). Is copy attached? Yes N o 9. Distn"bution 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.): t6insp.doc,-rev.7/26120118 Me 5 Offidal Inspection F'orm.Subsurface Sege Disposal System•Page 12 of 18 x Commonwealth ssachuseft T T ct'itle 5 Official Inspe ion Form Subsurface Sewage Misposal System r Not for Voluntary Assessments Propel Address Owner ear's Nam, information is required for eves page. City/Town State Zip bode Date Inspection D. System Inf a (coat.). 1 . Pump chamber(locate on site playa): ,fps working order.- IS10* fi El, Yes Alarms ire �rlraA.ur � r:, Comments (note coedit &- chamber,condition of pumps and appurtenances,etc.): r� Wlu if pumps or alarms are notin,working order, system is a conditional passe 1. Soil Absorption system (SAS)(locate on,site plan,excavaflon not required): If SAS not located, explain why: i Type'. 0, leaching pits number: leaching chambers number: El leaching gallenies number 0 leaching trenches number, len th.- l a bl fields number'. dimensions.- overflow cess l; nu b r El innovative/alternative system Type/name of technology: t insp.dooc rev.7/2612018 Otte 5 offidai inspecuon Firm:Subsuiface Sewage Disposal System-Page,13,of 1 Commonwealth of Massachusefts Ti le 5 Official Inspection For Subsurface Sewage Disposal System Foy Not for Voluntary Assessments Propel Address, ece Owner Owners Narn information is "Il required for evesit —ii" page. k State Zip Code Dateof Inspection D., Sstem Information (cont. 11. Soil Absorption System(SAS) cunt. Comments(note'condition f soil, si gns of hydraulic failure, level f ponding, damp,soil, condition of vegetation,etc.)., , A,)0110 Po v mmrv4 W Cesspools(cesspool must be pumped as,part of inspection)(locate on site plea): Number and configuration Depth fop of liquid to inlet,invert Depth of solids layer Depth ofscum layer Dimensions of cesspool Material's of construction; Indication ofgroundwater inflow Yes No Comments(note,condition of sail, signs of hydraulic f llr M,level of p r ding, condifionl of,vegetation, etc.)-. ,Q k 3/nmmV 10 mm'P pmm �'hidlIlli G w gnu mm u,imr t6i nsp.d oc-rev.7/26R01 8 Title 5 Offidal Inspecton Farm.' 1Jb's rfaw Sewage 01sposal System-Page 14 of 18 Commonwealth of Massachuseft T Egan itie 5 is a ection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owne fs Narne� inf6mation is required for ry (A I page. City/Town Mate Zip Code Date of Inspection M System Information (cont.) 13. Privy(locate on,site plan).- terials of construction: a Dimensions Depth of solids, ing cond ,of,vegetatio� Comments,(note co'ndition of so nd soil,signs of hydraulic failure, level of porgy , ition n, etc.): nil cirri ............. 1e 5 Official Inspection Form:$ubwfao$eWO99 0,40"1 45t0m, POP 16 Of 18 t5in sp,dao-lmv,712612018 Commonwealth of Massachuseft Title 5 OTTicial InsIr%ection For t Subsurface Sewage Ditsposal Systlem, For Not for Voluntary Assessments Property Address Owner Owners infoffnation is 117 required for every page. it State Zip Code Date 6i-inspection D., System Information tw, 14. Sketch Of Sewage Disposal System,: Provide a view of the sewage disposal system, inc6ding 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 bellow E] drawing attached"separately 7 P. s�manj "I....... C."'.001,00",................. ........... ..........................`­, ....dam.. ........... 60." W­­,,hfi­h C,� Wnsp..doc:-rev.7/26120,18 riflo 5,Offidal,Inspection Form:Subsurface,Sewage Disposal System-Page 16 of 18, AV% ria Commonwealth of Massachusetts o r Title 5 uTTicial Inspection r Subsurface Sewage 101sposa!System Form Not for Voluntary Assessments Al Property Address loll Owner Owners N infornlation is 40 , re,quire,d for every page. City/Town State Zip Code Date of Inspection D. System, I oa (cont.) 15. Site Exaiw 0 Check Slope Surface water 4" Check cellar 0 Shallow wells Estimated depth to high ground water., feet Please indicate all methods used todetermine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed'. Date �Obs,erved site(,abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health- cumentation ec explain- ( do ) Chked with local,excavators installers attach Accessed USGS database-explain: You,mulst describe how you established the high grouj:@ water elevation: KAI(Im w l A-3 Will Before fifling this Inspection Report, please)see Report Completeness Checklist on next page. t6linsp.doc rev,712M01 0 Ve 5 Offlicial Inspection Form,Subsurface Sewage DOOM SYstem-Page 17 of 18 Commonwealth of Massachusetts .......... I AM x cial Insr%ection For Subsurface,Sewage Disposal System Form Not for Voluntary Assessments &A Property Address Owner 0' erjs Nam required for every infonn,ation Is j,7t9, page,, eCity/Town S ate Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information-. Complete all fields in this,section,. B. Certification:Signed&Dated;and 1, 2,3,or 4 checked PC. Inspection Summary.- 1 1 21 3,or 5 completed as appropriate 4 (Failure Criteria)and 16(Checklist)completed D. System Information.- For 8: Tight/Holding,Tank—Pumping contract attached For 14: Sketch of Sewage,Disposal System drawn on pg. 16 or attached, For 15: Explanation of estimated depth to high,groundwater included rc t5insp.doc,-rev.712612018 We 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18, ORT" oJA Town of North Andover HEAL'fH,DEPARTMENT "SACHU CHECK 4: 7 DATE: �w,ln. ".. „��Y�"'"-' „rJ: /0 a. LOC ATI ON: H/O �. NAME WC' IdOW"„� YMI!�1 VI "MM';N/UI� .. CONTRACTOR NAME: O or,Lit icerlse"w"(Chec Ix) 01 Aniniat 0 Body Art Establishtnent $ 0 Body Art,Practitioner $ 0 D'unipster 0 Food Service— 0 FuneralDirectors 0 Massage Establishment $ El Massage Practice $ 0 offal(Septic) 0 Recreational Camp $ 0 Sun tanning 0 Swimming P0,01 0 Tobacco, $--------------- 0 Tra,shlSoilid Waste Hauler 0, Well Construction $ 'ISO Septic-Soil Testing 0 Septic—Desipt Approval $ is As Construction(DWO $ [3 Septic D1 posal'Wo 0 Septic Disposal Works Installers(DWI) 0 Title 5 hispector Title 5 Report D El Other.,, Indicate) $ He I -A- t I itials r White-Apph I cant Yellow-Health Pink,-Treasurer -'---------------- I �- ..