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380 Septic Repair Application 1999 Peter 1.McErlain Health Agent FORM 1 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587-1214TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM A. OWNER HOUSEHOLD INFORMATION Name of Owner(s): Mailing Address. Mediae(AAbb c_SQ,t% V7nyt , . 4b&KSSa 380 NiesIerJzi6 ,&ad Leeds;/n4- 9e5s Home Tele.hone: Work Tele.hone: 2 2 B. Property Location: Number of Occupants: PROPERTY INFORMATION 3 Cbegiaref'/�o,Q! Lama's /2V9- Ci2.fL? 1 Bedrooms: 1 V C. HAS A CERTIFIED INSPECTOR DETERMINED YOUR SYSTEM TO BE "FAILING"? YES NO ■ (ATTACH REPORT) D. HAS A PECOLATION TEST AND/OR DESIGN BEEN PREPARED OR CONDUCTED? YES ® NO ■ IF SO PLEASE EXPLAIN BELOW. (ATTACH REPORT) E. ARE THERE CURRENTLY ANY LIENS OR ATTACHMENTS RECORDED AGAINST YOUR PROPERTY? YES ® NO ■ Explanation: crnitii eV-V.40 - rrst Yi e6 : 4122 2�. r� SIGNATURE OF OWNER: DATE: 7/3/7 Peter.1 McErlain Health Agent FORM 2 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587— 1214 TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM MAP OF PROPERTY FROM ASSESSORS OFFICE PLEASE ATTACH COPY OF ASSESSOR'S MAP TO THIS FORM. .`_- 60% J)) L'� �ir' J r '/� I \klik tCrighbii VP7 7 s1 LOOK EMORIAL PARK w ski' Peter J.McErlain Health Agent FORM 3 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587-1214TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM REGISTRY CERTIFICATION OF TITLE PROPERTY LOCATION: e �'l /ad Poadj /e . s �, Q/eO •C, [LLOT STREET: 'CAes /A 7� L�7 S7t-� e�GiL 3U MAP /� # D// OWNER(S) RECORD: l / / �11 /lchda Ore /4bl teSS2, 4: V T%nyd Z. A/kkccCL ADDRESS: age O7ese/Afd ROaa /eats: m,i" O/O53 I HEREBY CERTIFY THE ABOVE ARE ALL THE OWNER(S) OF RECORD FOR THE SUBJECT PROPERTY AND ARE LISTED AT THE HAMPSHIRE COUNTY REGISTRY OF DEEDS, NORTHAMPTON, MASSACHUSETTS IN: BOOK #: S(e59 SIGNATURE: PRINT NAME: PAGE #: /ut chket ,,4-• 416M-ICs T47 7 . ,4A/ c `CS.ra.... TITLE: /Jai/et-5 DATE: 7/3,97 Peter J.McErlain Health Agent FORM 4 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587- 1214TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM TAX COLLECTOR'S CERTIFICATION PROPERTY LOCATION: C Q ehesier4erd teals »"- STATUS STREET: du n 1 ernCi PaCd MAP /5- LOT# 67/ W OF(S) RECORD: t e/ A - ratact ca_ Jr -* 7&nya 2 , 4.4Latessec. )V/A, ADDRESS: 384 %eile e/e Road /Peels, /OiM O/DSJ ITEM WATER ASSESSMENTS AMOUNT $ � STATUS SEWER ASSESSMENTS $ NAY REAL ESTATE TAXES $ OTHER (Describe) $ )V/A, SIGNATURE: Tax Collector DATE: COMMENTS: THE BOARD OF HEALTH WILL NOT LOAN MONEY TO ANYONE HAVING A BALANCE DUE. Peter 1.McErlain Health Agent CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587— 1214 TEL (413) 586— 1264 FAX FORM 5 SEPTIC SYSTEM REPAIR PROGRAM ASSESSOR'S STATEMENT OF VALUE PROPERTY LOCATION: bb L�l °LeCds, 01A' 3 e it/€s4 etd /cag STREET: e est /_!®�C� g©R _� // �j L` LcGt MAP /� LOT# iv/ OWNER(S) RECORD: �tlJ Niihau A-, A-b&ess2, it Y ranyeL / , /4LnitS ADDRESS: SefD Chesfed�e%I Rom° Zees /»2,9- 0/05T THE ABOVE REFERENCED PROPERTY IS VALUED AT $ THE CITY OF NORTHAMPTON ASSESSOR'S RECORDS. ACCORDING TO SIGNATURE: PRINT NAME: TITLE: DATE: COMMENTS (If any required): Peter J.Mc Erlain Health Agent FORM 6 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton,MA 01060 (413) 587 — 1214 TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM STATEMENT OF FACT PROPERTY LOCATION: ?86 he$ / r /e11 H(gd, - 5 ,'n.q_7 5j V (q/ 4/t r./7 NAME(S) OF OWNER(S): / gZIGh(l.�/ 4-,�/x�iCS,� �r 1% Tq/?efiL 15.303: Systems Failing to Protect the Public Health and Safety and the Environment A. Criteria applicable to all systems: 1. there is backup sewage into the facility served by the system or any component of the system as a result of an overload and/or clogged soil absorption system or cesspool; YES X NO LI 2. there is a discharge of effluent di ectly or indirectly to the surface of the ground through ponding, surface breakout or damp soils above the disposal area or to a surface water of the Commonwealth; YES NO X 3. the static liquid level in the distribution box is above the level of the outlet invert; YES LI NO /1 4. The liquid depth in a cesspool is ess than six inches from the inlet pipe invert or the remaining available volume within a cesspool above the liquid depth is less than '/ of one days design flow; YES 1 NO 5. the septic tank or cesspool requires pumping more than four times a year; YES 1 1 NO 1 XI 6. the septic tank is cracked or is otherwise structurally unsound, indicating that substantial infiltration is occurring or is eminent; YES LI NO x 7. a cesspool, privy or any portion of the soil absorption system extends below the high groundwater elevation; YES Li NO S. other reason(s) as to why system is no working or has failed: IS YOUR YEARLY INCOME $150,00.00 OR GREATER? YES I I NO 1 k PLEASE GIVE US AN ESTIMATE OF YEARLY INCOME OFF W-2 OWNER(S) OF PROPERTY: TO THE BEST OF MY KNOWLEDGE THE INFORMATION IS TRUE AND CORRECT. By: By: Date: 2/409 Date: /7/43/9 Please attach any reports you may have on this septic system. STOP- DETERMINATION BY THE BOARD OF HEALTH SIGNED: SIGNED: Healtbl.gent Chairman, Board of Health 2 Date: 7//7 /7 / Date: Peter 1.McErlain Health Agent FORM B CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587- 1214 TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM CONSTRUCTION CONTRACTOR PRICE QUOTES PROPERTY LOCATI 3N: ,_39-6) Cm J IL/4_4._ z r� ,%C / ye / /1/ Quote NAME(S) OF OWNER(S): iila, ���� /j Z���C' f� iii,y[ G/f, The following information is required. You must contact three (3) construction contractors to get prices on septic system installation costs. Price needs to include construction work required to complete installation in accordance with approved design plans. 1. COMPANY NAME: ADDRESS: PHONE NUMBER: WHO YOU SPOKE WITH: lR Price $ 37 Quote Zigna COMPANY NAME: ADDRESS: Price Quote PHONE NUMBER: WHO YOU SPOKE WITH: 3. COMPANY NAME: Price $ .00 F37. ; ADDRESS: Quote ADDRESS: V a PHONE NUMBER: WHO YOU SPOKE WITH: 4. COMPANY NAME: Price Quote $ .00 ADDRESS: I PHONE NUMBER: WHO YOU SPOKE WITH: 5. COMPANY NAME: Price $ .00 4-, ADDRESS: Quote z :• PHONE NUMBER: WHO YOU SPOKE WITH: PLEASE CHECK WHICH CONSTRUCTION CONTRACTOR YOU PLAN TO USE. Peter J.McErlain Health Agent FORM 8 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587— 1214 TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM CITY ENGINEER STATEMENT OF SEWER CONNECTION PROPERTY: STREET: MAP LOT# OWNER(S) OF RECORD: ADDRESS: IT IS THE DETERMINATION OF THIS DEPARTMENT THAT THE PROPERTY IN QUESTION IS UNABLE TO BE CONNECTED TO THE CITY SEWER SYSTEM AT THIS TIME, FOR THE FOLLOWING REASON(S): SIGNATURE: Engineer TITLE: PRINT NAME: DATE: Peter J.McErlain Health Agent FORM 9 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587— 1214 TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM PROJECT BUDGET PROPERTY LOCATION: 2 // , r CONSTRUCTION OF SYSTEM: STREET: q MAP LOT# OWNER(S) OF RECORD: % ltGfl-tewi 9 1� (Lu .4I La1c°ss°- ADDRESS: 3CD Ckg A_1_,,`ter /2j, & ESTIMATED COST OF: PERCOLATION TEST & DESIGN: $ .00 CONSTRUCTION OF SYSTEM: $ »l G. l Z .00 TOTAL AMOUNT REQUESTED: $ /t-/ Gtnv .00 STOP AMOUNT APPROVED BY THE BOARD OF HEALTH $ iy 4767' .00 PAYMENT SCHEDULE: SHALL BE 100% AT COMPLETION AND APPROVAL OF DESIGN. SHALL BE 50% UP FRONT TO BEGIN CONSTRUCTION. SHALL BE REMAINING 50% WITHIN 30 DAYS DAYS OF LETTER OF COMPLIANCE FROM THE NORTHAMPTON BOARD OF HEALTH. a a SIGNED AND APPROVED BY: Northampton Board of Health DATE: G-y242Erlain Agent