Loading...
HomeMy WebLinkAboutPass - Title V Inspection Report - 30 OLD CART WAY 8/30/2022 Commonwealth of Massachusetts Title 5 Official Inspection Form11 �f ��`�°�°�'� �Ea Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a NpV P love Property Address — Owner O ers ame information i1, � required for every Jl}�.✓l- _�- page. e City/1 own State Zip Code Date of Insp ection 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 P on the computer, use only the tab key to move your Name Irispettort cursor- not use the return key. Com y ame } I u, Corn Address Crwown State r - 4 2.-_ ? , _! S / 1_:'?l �` �/ Zip Code Tel ne epho Number LicenseNumber 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 Inspect gnature Date The system inspect o shall bmit 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.7r28/2018 - Tide 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 1 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address - Owner ff Owner's Name information is required for every J It I ",z I ✓ -� % � —Z? -G�— page. /Crtyrrown 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: 2) System Conditionally Passes: ❑-10ne 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 Ord of Health,will pass. Check the box for." es", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please lain. The septic tank is metal an er 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infi ion or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is repla with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is st urally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y rs old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.MWQ018 Title 5 O(fidal Inspection Form: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 t � c , �- ' Owner Property Address information is --- -- � Owner's Name l required for every �l- 6 V t/ � �— -2"2_ Z page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cons.) 2) System Conditionally Passes(cunt.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. ❑ Observation of age backup or break out or high static water level in the distribution box due to broken or obstru pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with roval of Board of Health): ❑ broken pipe(s)are repla ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obs ted pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑�,�broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain belo ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Hea ❑ Conditions exist which require further evaluation by the Board of Heath in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address - Owner s Name information is 4 rL ry> ) S 2 required for every /(� � �" v' page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) C ❑ \ 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 dird ss the Board of Health(and Public Water Supplier, if any) determines that the syst is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and 'I absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tribut to a surface water supply. ❑ The system has a septic tank and SAS an a SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SA ' within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less an 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laborat , for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 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 ❑ 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 t5insp.doc.rev.7262018 71tie 5 Offidal 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 Wi 7 t. bra Property Address --- —. Owner owner's Name information is required for everyG page. City/Town State Zip Code Date of inspection C. Inspection Summary (cont.) 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 ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than Yz 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. ❑ 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. ❑ A� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ M 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. The system faits. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large stems: To be considered a large system the system must serve a facility with a design flo ` f 10,000 gpd to 15,000 gpd. For large s 1 ms,,you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section C�.4. Yes No ❑ ❑ the system is withi 00 feet of a surface drinking water supply ❑ ❑ the system is within 200 fe of a tributary to a surface drinking water supply ❑ the system is located in a nitroge sitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II o public water supply well t5insp.doe-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal S ystem-Page 5 of 18 Commonwealth of Massachusetts �. Title 5 official Inspection Form ( 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments IL1— b3l-13 Property Address Owner Owners Name information is L/C C(/j') , required for every C J 5F `�1� 2-2 " page. CityfTown 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 an inspections: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ A, Were any of the system components pumped out in the previous two weeks? k ❑ 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? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components,excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example,a plan at the Board of Health. 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)] nnsp.doc•rev.7/26/21318 Title 5 official tnspeclion Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Cy A I-T Owner Property Address fp / C Owner's Name information is � 1 required for every A V 6 C l 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 15203(for example: 110 gpd x#of bedrooms): --�`-Description: Number 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 information in this report.) ❑ Yes, No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage (gpd)): --- / Detail: Sump pump? ❑ Yes W No Last date of occupancy: ��vL C Date t5insp.doc•rev-7/26/2018 - Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �- p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 3 Property Address — wne1's Name Owner G VL O f information is required for eve ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditipas—__ Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per da dj Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Watertreatment unit present? �! / El Yes ❑ No If yes, discharges to: ,J Industrial waste holding tank pp nt? El Yes El No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date occupancy/use: Date Othiir(describe below): 3. Pumping Records: 1rot�S1 � Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/262018 'Fide 5 Official Inspection Form:Subsurface Sewage Disposal system.Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 c) c f J Qqi. L v �- Property Address Owner Owners Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 4. Type of System: Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes Itno)(i 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: feed Comments (on condition of joints, venting, evidence of leakage, etc.): �U 'A R t5insp.doc•rev.7/28/2018 - Title 5 Official M . spection Fan:Subsurface Sewage Disposal Sys6ern-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is ��,,* t required for every —4 �[ r--T page. City/Town �— /-State Zip Code D e�pectim D. System Information (Cont.) 6. Septic Tank (locate on site plan): l� ?� s / Depth below grade: L2_ feet Material of construction: [concrete ❑ metal ❑fiberglass ❑ 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: _= ��o tl Sludge depth: � rP Distance from top of sludge to bottom of outlet tee or baffle r/ Scum thickness p� Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): t&nsp.doc-rev.7/26/2018 Title 5 Omw kq)eckm Form swmeaee SeVA9e MposA .page 10 of 18 ! � Commonwealth of Massachusetts Title 5 Official Inspection Form ra Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6IC Property Address ---- ------ Owner information is Owner's Nam` 1 l , n required for every -L..- page. Cftyffown State �P Code Date of inspection D. System Information (cone.) 7. Gc a Trap(locate on site plan): Depth belgrade: __- feet Material of cons ction: ❑concrete etal ❑fiberglass ❑polyethylene yl El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or ba — Distance from bottom of scum to bottom of outlet tee or ba Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle con ' n,structural integrity, liquid levels as related to outlet invert,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 y El other(explain): Dimensions: Capacity: ------------- gallons ---- — — - ----- Design Flow: gallons per day t5irisp.doc-rev.7262018 - Trtle5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 1e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner fe Owner's�7 ; � )� � information is i � ) ( ^� required for every `-! A/�t page. City/Town State Zip Code Date of tnspecEion D. System Information (cont.) 8. Tight or Holding Tank (cons.) Alarm` went: ❑ Yes ❑ No Alarm level: -- - Alarm in working order ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm 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.): �c i-j A:,t�t ►,— V'1 iL __j r`'A_JZ, 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 Subsurface Sewage Disposal System Form-Not fo r or Voluntary Assessments --� �� — Property Address --- Owner (.� % Owner's Name�J information is /� required for every 1 \r� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Patx�,ps in working order: ❑ No* ❑ Yes Alarms in wor ' order: ❑ Yes ❑ No* Comments(note condition o p chamber,condition of pumps and appurtenances,etc.): 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 number, dimensions: — ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts 0 Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - c' Cam(A `" �-- Property Address — x z j �A>2 Owner s � information is P (-� required for every �� 'CJ 6 12 G� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): _ 5 /I CR-� ) ✓1 ridgy~ems. �.��� �trti,� � °'1;�-- 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration _ Depth,—top of liquid to inlet invert — Depth of so' s layer Depth of scum Jaye Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic fai el of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Seva ge Disposal System•Page 14 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Owner Property Address Owner's Name information is n J y1� �i r— required for every ���L, \ d,/1i� �\r' t� i�`l L: IO 6 ,�--� 2 page. City/Town State Zip Code DaWy of Inspection D. System Information (cont.) 13. PrivyTbcate on site plan): Materials of construction: -------- — _ Dimension Depth of solids Comments(note c dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -_t5insp.doc-rev.712&2018 - - Title 5 Official Inspection Fromm..Subsurface sewage Disposal System.Page 15 of 18 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V� Property Address - �k' ►� .� Owner Owner's Name I information is y� (, �� / yVOCN, required for every J�• page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 14. S :each 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 To C'_ A 313r, t , d e_ J,. '-cam s. t5insp.doc.rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 0 Commonwealth of Massachusetts ,. ,p Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C�0 , Property Address Owner Owne's Name information is gnu required for every LA- V - G3y�1.—_ page. City/Town State Zip Code Date of Irilspectim D. System Information (coat.) 15. Site Exam: Check Slope Surface watery ( 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. t5msp.doc-rev.7/26i2018 "filie 5 Qifidal Inspection Form:Subsurface SeHage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal posa!System Form-Not for Voluntary Assessments 3 Property Address 6 Owner O vnrv-r a Name Q information is required for every +^ C,t."�._. S��j '� _ G - page. �tylf tate 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 [ 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 �MO RiM F f :; Town of North Andover HEALTH DEPARTMENT SACMUSt CHECK#: S/ 89 DATE: 06 30. ao.22 pp LOCATION: k / 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: O Septic-Soil Testing $ ` ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report PbU5 F t l ❑ Other. (Indicate) $ i ealth Agent Initials White-Applicant Yellow-Health PPir k-Treasurer