108 Title 5 System Repair Loan Program Documents Peter J.McErlain
Health Agent
FORM 1
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton, MA 01060
(413) 587- 1214 TEL
(413) 586-1264 FAX
SEPTIC SYSTEM REPAIR PROGRAM
P
JAN 1 0 1998
;AMPTON BOARD OF HEALTH
A.
Name of Owner(s):
OWNER HOUSEHOLD INFORMATION
74 Ines t ,4Ad✓E Koh,mnn/
Mailing Address'
/o8 MS)?.i.94/ sr xa-r
4.49.¢rh'Ain®7-€24/ ,p - eve, 6 D
Home Telephone:
Q6 9f6- Work Telephone: I _IPA-y.ac
B.
Property Location:
PROPERTY INFORMATION
/oa .sf Ec 7
ar za CH.v✓✓e�.
Number of Occupants:
4-
Bedrooms: I 3
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 C NO ■ IF SO PLEASE EXPLAIN BELOW.
(ATTACH REPORT)
E. ARE THERE CURRENTLY ANY LIENS OR ATTACHMENTS RECORDED AGAINST YOUR
PROPERTY? YES ■ NO M
Explanation:
SIGNATURE OF OWNER:
DATE: /_2/19/9-7
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:
/0,, H.
Sac
STREET:
1174/C4i S?2EE7"
MAP
is
LOT#
7g,
OWNER(S)
OF
RECORD:
#%' v'E A J,gm6S 0X1^/79 /7�
ADDRESS:
/d) 47Atr,fd ss,RE-J
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 #:
,92'09
SIGNATURE:
PRINT NAME:
PAGE #:
TITLE: lnlnrvnn a&., a
CaaF 4-A-attiiU
DATE: 1 .2-.29-97
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:
/O 4 e l l P F X-7-A i l/ 3 7
STATUS
ii
STREET:
Aier /
MAP
/3
LOT#
,17-
OWNER(S)
OF
RECORD:
�°�' /
1AV,4 4/E i- 1''9"41SS KJ,64,12 AF4-✓
ADDRESS:
/a f h7A,PZAn/ s7-ea-7-
ITEM
WATER ASSESSMENTS
AMOUNT
$ //o. 9c
STATUS
ii
SEWER ASSESSMENTS
$ Ai• /A)
REAL ESTATE TAXES
$ ��Q6
OTHER (Describe)
$ ���
SIGNATURE:
Tax Collector
DATE:
/'/29/97
COMMENTS:
THE BOARD OF HEALTH WILL NOT LOAN MONEY TO ANYONE HAVING A BALANCE DUE.
Peter1 McErlain
Health Agent
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton, MA 01060
(413) 587— 1214 TEL
(413) 586- 1264FAX
FORM 5 SEPTIC SYSTEM REPAIR PROGRAM
ASSESSOR'S STATEMENT OF VALUE
PROPERTY LOCATION:
/a f fhae2sr/ S% %
STREET:
4 X44/
° �
MAP
. n
LOT#
OWNER(S)
OF
RECORD:
yr-4�
sd `a.q »aS
east/Ain 94/
ADDRESS:
iO 0
47..0572.,tAV
SZteer
THE ABOVE REFERENCED PROPERTY IS VALUED AT $
THE CITY OF NORTHAMPTON ASSESSOR'S RECORDS.
ACCORDING TO
SIGNATURE:
PRINT NAME:
TITLE: 2-11ALti nat aLaary
DATE: J - a - 'j 7
COMMENTS (If any required):
Peter I McErlain
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:
/61 "17.422..7-,44/
57,21Z7-
NAME(S) OF OWNER(S):
)9,0174/.E t 0:liAm C
O1177/FA/
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 _ NO
2. there is a discharge of effluent directly 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 I
3. the static liquid level in the distribution box is above the level of the outlet invert;
YES I NO Li
4. The liquid depth in a cesspool is less 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, I NO LI
5. the septic tank or cesspool requi es pumping more than four times a year;
YES I I NO
1
6. the septic tank is cracked or is otherwise structurally unsound, indicating that
substantial infiltration is occurring or is eminent;
YES
NO
7. a cesspool, privy or any portion of the soil absorption system extends below the
high groundwater elevation;
YES
NO U
8. other reason(s) as to why system is not working or has failed:
IS YOUR YEARLY INCOME $150,00.00 OR GREATER? YES I NO 23
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-
Date: I/ /6 / yr
Please attach any reports you may have on this septic system.
STOP
DETERMINATION BY THE BOARD OF HEALTH
SIGNED:
SIGNED:
alth Agent
Chairman, Board of Health
2
Date: i/ /711-
Date:
Peter1 MCGlain
Health Agent
FORM 8
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton,MA 01060
(413) 587— 1214 TEL
(413) 586- 1264FAX
SEPTIC SYSTEM REPAIR PROGRAM
CITY ENGINEER STATEMENT OF SEWER CONNECTION
PROPERTY:
4'1C4119/1/
STREET:
to et ,42gj/H.r/ -Sf.
MAP
LOT#
OWNER(S)
OF
RECORD:
/i ,- ,y, yam/
_
J sin, c s 7- f/ ,✓N c
ADDRESS:
/O e h?f3,P.//9.i/ .577 ,YO.e_r/Y/➢-An? To�.fry
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:
PRINT NAME:
Engineer
TITLE:
DATE:
Peter 1.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:
/4t /it riE/q,✓ st
STREET:
/O1 /144/44 5f
MAP
$ .00
LOT#
OWNER(S)
OF
RECORD:
J,y", ES
t 79/1,•4/E
Abel/A r at sv../
ADDRESS:
/0 P
/Wile//fi/ 57'
4704 f41HtsO/c.✓/
ESTIMATED COST OF:
PERCOLATION TEST & DESIGN:
$ .00
CONSTRUCTION OF SYSTEM:
$ 4 99G. 3G .00
TOTAL AMOUNT REQUESTED:
$ ,996. 34.00
STOP
AMOUNT APPROVED BY THE BOARD OF HEALTH
.00
PAYMENT SCHEDULE:
SHALL BE 100% AT COMPLETION AND APPROVAL OF DESIGN.
p
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.
SIGNED AND APPROVED BY:
Northampton Board of Health
DATE:
Pet cErlain, Health Agent
/111115/
Northampton Septic System Repair Loan Program
Bill for Repair of
Septic System
Date: January 8, 1999
To: Northampton Board of Health
From James Kohrman
210 Main Street
108 Marion Street
Northampton., MA 01060
Northampton, MA 01060
>
Cil}F; onttact
Repair of failed septic system at 108 Marion Street in accordance with approved plans.
Connection to city sewer system was completed on 12/18/97
Approved cost
$3,285.00