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HomeMy WebLinkAboutPass - Title V Inspection Report - 259 GRANVILLE LANE 11/18/2019 Commonwealth of Massachusetts ,�,p Title 5 Official Inspection Form fill= iin Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner O wners Name information is required for every 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:When D filling out forms A. Inspector Information on the computer, nt use only the tab key to move your 1,44ime of Inspector cursor-do not - Of N OFM use the return Company Name TO II)VIN M oT key. >� t�s Company AddressIL AP �q Cite State �» Zip Code rat '� '"���" d� GT ILI 4� Telephone Number License Number B. Certification 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. X,Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspectors Signature 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 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 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pro arty AcIdress Owner Owners Name information is QV-:% required for every page. City/Town State Zip Code Date of inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not found any information which indicates that any of the failure criteria described 'n 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: r 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ~� Prote;W A dress Owner O er's Name information is o f�r i ���� K In, c t sl � 1 required for every '�\ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System C nditionally Passes (cont.): ❑ Pump C amber pumps/alarms not operational. System will pass with Board of Health approval if pumps/al rms are repaired. ❑ Observation f sewage backup or break out or high static water level in the distribution box due to broken or o structed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspectio if(with approval of Board of Health): ❑ broken p e(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstructio is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution x is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping ore than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(wl approval of the Board of Health): ❑ broken pipe(s)are replac ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of\aanner ❑ Conditions exist which require further evaluatio of Health in order to determine if the system is failing to protect public health, saironment. a. System will pass unless Board of Healthn accordance with 310 CMR 15.303(1)(b)that the system is not functioni which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form r155 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P' ( f kv Pro a Ad ress Owner Owner's Name information is „ �1 ( /l required for every fff tititi[[[111V(( y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspo I or privy is within 50 feet of a surface water ❑ Cesspool r privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail Mess the Board of Health(and Public Water Supplier, if any) determines that the ystem is functioning in a manner that protects the public health, safety and environm nt: ❑ The system has a s tic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface wat r supply or tributary to a surface water supply. ❑ The system has a sep 'c tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic ank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic to k and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supp well Method used to determine dista e: **This system passes if the well water alysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no of r 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 clogged 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P p rty Address R p t� Owner owner's Name information is required for every � M /1 O1 � t0 19i �f �1l`++ " , \.V � page. City/Town State Zip a Date of Inspection C. Inspection Summary (cost.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 1�yA Liquid depth in cesspool is less than 6"below invert or available volume is less N� than '/z day flow ❑ 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. �❑�J� 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 water supply 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.] ❑ ?t� The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails. 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 considered a large system the system must serve a facility with a design flow of 10,000 d to 15,000 gpd. For large systems, you m t indicate either"yes"or"no"to each of the following, in addition to the questions in Section C-A. Yes No ❑ ❑ the system is witlriti 400 feet of a surface drinking water supply ❑ ❑ the system is within 20 eet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a ni gen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zo II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property dress Owner Ow er's Name information is required for every �f 1 �?L� �� IVI page. City/Town State 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 CA 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 ❑ -r9d Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ 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? 1 ❑ 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: 106cr+lf ❑ Existing information. For example, a plan at the Board of Heal- ❑ 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)] t5insp.doc•rev.7/26/2018 'nUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pro pe A dress - *U v i G� Owner Owner's Name information is required for every page. City/TownTr State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: A , Number of bedrooms(design): Number of bedrooms (actual): q Mi DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes K No information in this report.) Laundry system inspected? 'C�r Yes ❑ No Seasonaluse? ❑ Yes [' No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes'K No Last date of occupancy: C unw'tf Date /o/3�11� t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Propegy qdress i j VcAr Owner Own r s Name information is t C required for every r� L C(L L'" 01 page. City/Town ' State Zip Code Date of Inspection D. System Inform ion (cont.) 2. Commercial/Industrial Flow onditions: 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? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Cvrro1 It Last date of occupancy/use: Date 101-31111 Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes�g[ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Prop rty ddres () (. �tcr�'l Owner Ow e s Name information is btl a /1_ � .f_ nn„4 (�i t f ( ( tq required for every 't"'4 f'Cy`�.� !r Lf1o'-�'L 1 �-LLl page. City/Town S ate Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron �40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f.- i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Gra,],A' f v Pro e A dress �1 Vo U\- Owner Ow efd Name _ evil/ _ n n (0 J n f f (� information is / J�1 , �/1�/11-f- li ( '"�( required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): !� 1 14 fti-clv5 Depth below grade: feet Material of construction: concrete ❑ metal Elfiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle L' J� 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 1 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tom, zar Uj, 4XV 4W �1 1�'� A) 'PA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �- F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �-' lira( U V. Owner Owr}er's Name information is A!. �r� required for every 1 V �� �lam-{ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap ocate on site plan): Depth below gra e: feet Material of constr ction: ❑ concrete ❑ metal El fiberglass El polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scu to top of outlet tee or baffle Distance from bottom of sc to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recom endations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet i ert, evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pu ped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El concrete El metal ❑fib lass ❑ polyethylene ❑ other(explain): Dimensions: . Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 /01 Commonwealth of Massachusetts �- Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Pro A dress T�'\ 0 1 Owner py�n r s me information is every f 1 /�, ,/Z T , t?� f f/3 required for eve �� ��r 1 (� I��Co L�7 l page. City/Town State Zip a Date of Inspection D. System Informal . n (cont.) 8. Tight or Holding Tank(cont.) Alarm present: C® Yes ❑ No Alarm level: Alarm in working order: tom+,Yes ❑ No Date of last pumping: Dat Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? �Fjes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): ( (�- p Depth of liquid level above outlet invert I ``�� �'f"' 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.): t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 lip r�oq' Ci l{✓� � zI �. Pr— Address �L'2' Owner O ner's Name information is0��,�;a I. (� required for every Y 't'i,�'1 m�% -- ,l 4 page. City/Town State Zip Mde Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: LLYes ❑ No" Alarms in working order: ',K Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): r-^- * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits �� number: IK leaching chambers,"' number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ILL I%A N) AN)evir -� Pr p rty A dress 4 1k Owner Own is Name information is tea t),r required for every t%Uf �ia '�`� ''�_ page. City/Town State Zip a Date of Inspection 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.): - dry- to .:fteld �1 6 !�Se/q/) cn-�'/—' �,- 12. Cesspools (cesspool must b 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 Comments (note condition of soil, signs of draulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sypstem Form -Not for Voluntary Assessments in .4/,, v Property Add e�ss? -KC'.(,�V Owner Owner's Name information is y, / required for every 1G .� (�:�r r►v l ``�l/ 6/q ` page. City own State VZipokde Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition\signsof failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Prop rty dress Owner Owners Name tl� information is required for every �— page. Citifrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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: and-sketch in the area below drawing attached separately Joe (Q� V-} - C I la 40 , a 4 LAY44 P— t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (r 1. .hut u fit Prope Address ` dress Owner Owner s Name information is lh 1 fi /1 d&t „ / �1�1. l2 !1 �;r required for every N U rth 'U�f (Y L�f" "7 page. City/Town State Zip a Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope ❑ Surface water ❑ Check cellar ❑ 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) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: cdllz rl � rn k o 6 Kv,- c3 I J'W de V C to c h � y -A-4 e-f- 14 Qt-47� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts • �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v!r� � '� �� k Prope Address A � OVI Owner Owner Nanle. information is 1 /�,� / required for every 21 ., AQ oy&r MYT — /613)l) q page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: r A. Inspector Information: Complete all fields in this section. i'JX B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed I� 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 3 ! i O` . O • : Town of North Andover HEALTH DEPARTMENT �SSUHus�� CHECK #( DATE: LOCATION: Z 9 C n H/O NAME: UZ-J:3�A CONTRACTOR NAME: 4a ill)6,/l Type of Permit or License: (Check box) ❑ 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems : ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report 5-5 $ ❑ Other. (Indicate) $ s Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer