HomeMy WebLinkAboutPass - Title V Inspection Report - 30 VEST WAY 8/5/2020 l
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 P 5 q
Pr perty Address ----
Owner O qr_s me informationisrequired for every 7� — Q
page. Ci y/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 ED
filling out forms A. Inspector Information
on the computer,
use only the tab CHARLES J. ROUX pUG
key to move your Name of Inspector
cursor-do use the return
TC �TH DEPA�MENT
CHARLES J. ROUX, LLC
key. Company Name
213 PATTEN ROAD
Company Address
TEW KSBU RY MA 01876
City/Town State Zip Code
978-640-9984 S 1891
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. [}[ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspec or's 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
.•� to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-L
Property Address --
Owner Owner's-Name -
information is
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
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
J1U a 0 GS Qr
a � C
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 t septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltra ' n or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a omplying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection ' it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is I s than 20 years old is available.
❑ Y ❑ N ❑ N (Explain below):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v�
Property Address
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) -
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level * the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or unev distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y N ❑ ND (Explain below):
❑ obstruction is removed ❑ ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced Y ❑ N ❑ ND (Explain below):
❑ The system required p ping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass ins ction if(with approval of the Board of Health):
❑ broken pi e(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ ob ction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluati by the Board of Health in order to determine if
the system is failing to protect public healt afety or the environment.
Aaark a. System will pass unlessXBoardolth determines in accordance with 310 CMR
15.303(1)(b)that the systemoning in a manner which will protect public health,
safety and the environmen
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osal posal System•Page 3 of 18
Commonwealth of Massachusetts
�e ,�3 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address ----__
Owner Owner's Name
information is
required for every _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Su ier, if any)
determines that the system is functioning in a manner that prote s the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system AS)and the SAS is within
100 feet of a surface water supply or tributary to a surface ter supply.
❑ The system has a septic tank and SAS and the SAS ' within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the AS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS an the SAS is less than 100 feet but 50 feet or
r more from a private water supply well".
Method used to determine distance:
**This system passes if the well water nalysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent a the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided th no 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 all inspections:
,.. Yes No
❑ 21 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
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� %r
v
Property Address ----
Owner Owners Name ------
information is
required for every _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ d Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
440 Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
_,/ obstructed pipe(s). Number of times pumped:
ElLd Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Q' Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ a Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ 2,1 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 be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
.-Wft. ❑ ❑ the system /feet
of a surface drinking water supply
❑ ❑ the system i of a tributary to a surface drinking water supply
❑ the system irogen sensitive area (Interim Wellhead Protection
Area— IWPone II of a public water supply well
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Commonwealth of Massachusetts
�. p Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Qf
Property Address ----.
Owner Owner's Name
information is --
required for every
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 a//inspections:
Yes No
Er ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Q Were any of the system components pumped out in the previous two weeks?
d ❑ Has the system received normal flows in the previous two week period?
r
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
d ❑ 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?
d ❑ Was the site inspected for signs of break out?
IZI ❑ 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.
d ❑ 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
Title 5 Official Inspection Form
io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address ------
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information --
1. Residential Flow Conditions:
Number of bedrooms (design): — Number of bedrooms (actual),
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
Number of current residents:
AN".
Does residence have a garbage grinder?V6�iR'1�100m vtten/ [vj Yes ❑ No
Does residence have a water treatment unit? ❑ Yes [lf No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes [� No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? � ) _❑ Yes 5 No
v
Water meter readings, if available (last 2 years usage (gpd)): /'U 10UJA/ is
Detail:
Sump pump?
❑ Yes [� No
Last date of occupancy: _
Date
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Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
r-
.�. 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner pwner's Name
information is ---
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.) _--
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallo 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 itle 5 system? ❑ Yes ❑ No
Water meter readings, if availablef
Last date of occupancy/use: /
Date ----
Other(describe below):
3. Pumping Records:
Source of information: � � /P
Was system pumped as part of the inspection? Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
.uft, Reason for pumping: 'e/V �p
t5insp.doc•rev.7/2 61201 8 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�e P Title 5 Official Inspection Form
,,... Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% e
u� Property Address ----
Owner Owner's Name -----
information is
required for every _
page. City/Town State 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) an source of information:
-----� �rC (G -
Were sewage odors detected when arriving at the site? ❑ Yes [Z No
5. Building Sewer(locate on site plan):
Depth below grade: a
feet --
Material of construction:
0 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.):
.�
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Commonwealth of Massachusetts
�d ,�p Title 5 Official Inspection Form
.� 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address ---
Owner Owner's Name ----
information is
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
feet
Material of construction:
2 concrete ❑ metal ❑fiberglass ❑ poll th lene
Y ❑ other(explain)
If tank is metal, list age:
,,.� years
Is age confirmed by a Certificate of Compliance? (attach a cop)�of certificate) ❑ Yes ❑ No
Dimensions: (
Sludge depth: �o
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 ` y --
How were dimensions determined? — Uct
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
'
vle-
ev
�< _ _ I, � � It�c��N !C}/�►�� � � � ��r�.'�elr�' `-E~-�Tl��It�c;�W:::yL
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disp
osal posal System•Page 10 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
+ Q
v Property Address -
Owner Owner's Name
information is ---
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
feet --
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ po ethylene Y El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or afFle
Distance from bottom of scum to bottom of utlet tee or baffle -
Date of last pumping:
Date
Comments (on pumping recomm dations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet * vert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal fiberglass ❑ polyethylene
El other(explain):
100W. Dimensions:
Capacity:
gallons ---
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3
v
d Ues a _
Property Address -
Owner Owner's Name --
information is
required for every —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) �-
8. Tight or Holding Tank (cont.)
Alarm present: Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float itches, 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 �T/1
��)
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
q
Property Address
Owner Owner's Name —
information is ---
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan): /
Pumps in working order: Yes ❑ No"
Alarms in working order: El Yes ❑ No"
Comments (note condition of pump chamber, condition of pu s and appurtenances, etc.):
i
* 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:
❑ leaching chambers number: --
❑ leaching galleries number: --
❑ leaching trenches number, length:
leaching fields n
umber, dimensions:
r�. ❑ 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
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
..•. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-� 3o Ve
Property Address ----
Owner Owner's Name —
information is
required for every
page. City/Town State Zip Code 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.):
� l
12. Cesspools (cesspool must be pumped as part of inspection) (locate on si 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 hydraulic failure, level of ponding, condition of vegetation,
etc.): j
t5insp.doc•rev.7/26/2018 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u Property Address— � -----
Owner Owner's Name —_—
information is
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, el 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
�. p Title 5 Official Inspection Form
1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address ---
Owner Owner's Name ---—
information is
required for every
page. City/Town 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:
❑ hand-sketch in the area below
❑ drawing attached separately
l
t3ox
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
vV/ er Property Add
dress -----
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code 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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for every
page. City/Town State 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.
d 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
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
Summary Record Card generated on 7/27/202011:02:40 AM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-104.B-0166-0000.0
Parcel Id 16488
30 VEST WAY
KENNEY, FRANCES
30 VEST WAY
N. ANDOVER, MA
01845
Class 101 Single Family Property Type v
Size Total 1.08 Acres 1 Residential
FY 2021
UB Mailing Index
Name/Address Typo Loan Number Active/inact. From Until
KENNEY, FRANCES Payor Active
30 VEST WAY
N.ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/inactive
Bldg Id. 17835.0-30 VEST WAY Last Billing Date 7/8/2020
3170500 03 Cycle 03 Active
UB Services Maint.
Account No.3170500
Service Code Rate Charge Multiplier/Users
MISCFEEADMIN FEE 0.63 5/8 7.$2 1/
WTR WATER 01 ALL METER SIZE 125.95 /1
UB Meter Maintenance
ount No. 3170500
;vial No Status Location Brand Type Size YTD Cons
33605592 a Active ERT HH b Badger w Water 0.63 0.63 2738
Date Reading Code Consumption Posted Date Variance
6/5/2020 2935 a Actual 29 7/15/2020 47%
3/9/2020 2906 a Actual 20 4/8/2020 1 g%
12/11/2019 2886 aActual 16 1/15/2020 361%
9/17/2019 2870 a Actual 4 10/10/2019 %
6/11/2019 2866 aActual 15 7/25/2019 75 75%
3/11/2019 2851 aActual 19 4/16/2019 34%
12/11/2018 2832 a Actual 14 1/22/2019 208%
9/13/2018 2818 a Actual 5 10/15/2018 -69%
6/7/2018 2813 a Actual 15 7/23/2018 1
3/9/2018 2798 a Actual 15 4/23/2018 2%
12/8/2017 2783 a Actual 14 1/25/2018 209%
9/12/2017 2769 a Actual 5 10/18/2017 66%
6/8/2017 2764 a Actual 14 7/25/2017 %
3/9/2017 2750 a Actual 15 4/12/2017 3%
12/9/2016 2735 aActual 15 1/23/2017 -84%
9/7/2016 2720 a Actual 86 10/24/2016 119%
6/13/2016 2634 a Actual 43 8/2/2016 148%
3/11/2016 2591 aActua1 17 4/22/2016 -26%
12/10/2015 2574 aActua1 23 1/20/2016 -69%
9/9/2015 2551 a Actual 74 10/16/2015 70%
6/10/2015 2477 a Actual 43 7/24/2015 187%
3/12/2015 2434 a Actual 15 4/28/2015 -40%
12/12/2014 2419 aActual 26 1/15/2015 -78%
9/10/2014 2393 a Actual 119 10/15/2014 577%
6/9/2014 2274 a Actual 17 7/16/2014 12%
3/11/2014 2257 a Actual 15 4/11/2014 -78%
12/12/2013 2242 aActual 71 1/17/2014 -16%
9/12/2013 2171 a Actual 86 10/15/2013 35%
6/11/2013 2085 aActual 61 7/24/2013 215%
3/14/2013 2024 a Actual 20 4/22/2013 -69%
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CHECK#: . S DATE: a I .�. a�0
LOCATION: r 30 Vi,3 t a-
H/O NAME:
CONTRACTOR NAME:
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 $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWG) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector S c $
❑, Title 5 Report PO-- $
❑ Other:(Indicate) $
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Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
