41 Septic System Repair Program 1998 etc J.McErlain
Health Agent
FORM 1
Jame of Owner(s):
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton, MA 01060
(413) 587- 1214 TEL
(413) 586- 1264 FAX
SEPTIC SYSTEM REPAIR PROGRAM
OWNER HOUSEHOLD INFORMATION
CA20L !? L p41q
Mailing Address:
4t 0Lb FERQ7 20 Not?+JHm MTh, en
Home Telephone:
584-0449
Work Telephone:
$ 8• -1 for
Property Location:
PROPERTY INFORMATION
Lit VL 2D >✓oalg,,,Pflev
Jmber of Occupants:
`f
Bedrooms:
3
HAS A CERTIFIED INSPECTOR DETERMINED YOUR SYSTEM TO BE "FAILING"?
ES ri NO ■
(ATTACH REPORT)
HAS A PECOLATION TEST AND/OR DESIGN BEEN PREPARED OR CONDUCTED?
YES NO ■ IF SO PLEASE EXPLAIN BELOW.
(ATTACH REPORT)
ARE THERE CURRENTLY ANY LIENS OR ATTACHMENTS RECORDED AGAINST YOUR
PROPERTY? YES ■ NO Ei
.planation:
JGNATURE OF OWNER: a CLL e.. DATE: to t5, 54
cErlain
agent
1,1 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
RTY LOCATION:
3) OF OWNER(S):
Systems Failing to Protect the Public Health and Safety and the Environment
A. Criteria applicable to all systems:
f, 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 absorptin
cesspool; NO
YES
2. through ponding surface b enakoutcorydamp soi slabove the disposal ae ea to a
surface water of the Commonwealth;
YES a 140
3. the static iquid level in the distributionox is above the level of the outlet invert;
YES x NO
available volume within a cesspool above the liquid depth is less
4. The liquid depth in a cesspool is ess than six inches from the inlet pipe invert or
the remaining
than '/:of one day's design flow;
YES a NO
5. the septic tank or cesspool requires pumping more than four times a year;
YES a NO
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 X NO D
g. other reason(s) as to why system is not working or has failed:
t YEARLY INCOME $150,00.00 OR GREATER? YES
NO
GIVE US AN ESTIMATE OF YEARLY INCOME OFF W-2
t(S) OF PROPERTY:
BEST OF MY KNOWLEDGE THE INFORMATION IS TRUE AND CORRECT.
Date:
Date:
attach any reports you may have on this septic system.
STOP
1 D ( 2N 198
SIGNED:
SIGNED:
ealth Agent
/
Chairman, Board of Health
2
Date:
Date:
Erlain
gent
48
1111.
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
1111® LOT#
T:
,(S)
to
SS:
HE DETERMINATION
B E TO BECONNECTTED TO TTHE CITY SYSTEM AT THIS IS
TIME, FOR THE
FOLLOWING REASON(S):
a a.+ CID fee g
r..✓ q /ro Spwer �"
C i! C4rr )
�/ „f a sewer I�hL
n/0..5 CNrn.Ti
let
DATE:
s
t,4Qre
S� �p-i� irY
are
Erlaln
gent
VI 5
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton,MA 01060
(413) 587— 1214 TEL
(413) 586-1264FAX
SEPTIC SYSTEM REPAIR PROGRAM
ASSESSOR'S STATEMENT OF VALUE
RTY LOCATION:
t(S)
213:
SS:
LOT#
ONIN
ACCORDING TO
OY OF NORTHAMPTTON ASSESSOR'S ARECORDS.PROPERTY IS
4TURE:
r NAME:
a
• k
AENTS (If any required):
TITLE:
DATE:
tir
Erlain
gent
if 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
RTY LOCATION:
T:
t(S)
0:
SS:
PROJECT BUDGET
—sri. LOT#
ESTIMATED COST OF:
Co in Pc trr`n
PERCOLATION TEST &DESIGN:
CONSTRUCTION OF SYSTEM:
$ ¢5000
TOTAL AMOUNT REQUESTED:
$ te o�0�00
--------'----------------------------------------STOP-----------------------------------------------------
-----------
IOUNT APPROVED BY THE BOARD OF HEALTH
PAYMENT SCHEDULE:
SHALL BE 100% AT COMPLETION AND APPROVAL OF DESIGN.
SHALL BE 50% UP FRONT TO BEGIN CONSTRUCTION.
SHALL COMPLIANCE F OF
ROM THE NORTHAMPTON BO RD OF HEAD H.
SIGNED AND APPROVED BY: P1 ASI6r
if
Northampton Board of Health
DATE:
Pet
I1
c
McErlain, Health Agent
/8 ;o
Ertain
gent
44
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton,MA 01060
(413) 587 — 1214 TEL
(413) 586— 1264 FAX
SEPTIC SYSTEM REPAIR PROGRAM
RTY LOCATION:
T:
:(S)
tD:
SS:
ITEM
TAX COLLECTOR'S CERTIFICATION
'ER ASSESSMENTS
IER ASSESSMENTS
AL ESTATE TAXES
DTHER (Describe)
SIGNATURE:
DATE:
COMMENTS:
AMOUNT
T ® LOT# -
STATUS
Tax o e for
Pd .
E BOARD OF HEALTH WILL NOT LOAN MONEY TO ANYONE HAVING A BALANCE DUE.
;Eriain
.gent
1? 3
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton, MA 01060
(413) 587- 1214 TEL
(413) 586— 1264 FAX
SEPTIC SYSTEM REPAIR PROGRAM
REGISTRY CERTIFICATION OF TITLE
RTY LOCATION:
:T:
t(S)
2D:
SS:
THE SUBJECT
BY CERTIFY THE ABOVE ARE ALL THE OPERTY AND ARE LISTED AT THE HAMPSHIRE CODUNTRYEREG STRYOF DEEDS,
NORTHAMPTON, MASSACHUSETTS IN:
ATURE:
T NAME:
PAGE U:
TITLE:
DATE:
QUITCLAIM DEED
KNOW ALL MEN BY THESE PRESENTS That Henry G. Cisneros,through Secretary of
Housing and Urban Development,of Washinrefn,D .C.,as in'g b �ytan'd,for consideration
Federal Housing Commissioner,
paid of THIRTY•SEVEN THOUSAND ANDNNO/100 ($$337,000. We.DOLlARTenaoce by the anetrecy
grants to KURT A. BLAHA/of 576 Elm Street,Northampton,Hampshire County,
Massachusetts
with quitclaim covenants.
The land,with buildings, if any,thereon located at 41 Old Ferry Road,Hoonee tIortbaaytoa,
Hampshire County,Massachusetts, and bounded and described as follows:
See Schedule"A" attached hereto for a more particular description of the
property.
BEING the same property acquired by the grantor pursuant to the provisions of
the National Housing Act,as amended(12 USC 1701 et seq.) and the Department of
Housing and Urban Development Act(79 Stat 667),by deed f0 ted May Boo, 1 49 Page 232
and
recorded with the Hampshire County Registry of Deeds on
IN WITNESS WHEREOF the undersigned on this 21 lAday of April, 1995 has
set his hand and seal as Chief,Production and REO Branch,Office of Housing,FHA
Field Office,Boston,Massachusetts,for and on behalf of the said Secretary of Housing
and Urban Development,under authority and by virtue of the Code of Federal
Regulations,Title 24, Chapter 11,Part 200 Subpart D, and 35 F.R. 16106 (10/14/70), as
amended.
Sign •,jested in the
pre ce of:
Secretary of Housing and Urban Development
By: Federal Housing Commissioner
Robert F. Connie!
Chief,Production and REO Branch
FHA Field Office
Boston, Massachusetts
By
B c: Dan OR 1412N0125 BB1Th188515:48
COMMONWEALTH OF MASSACHUSETTS ) April 0,9, 1995
COUNTY OF SUFFOLK )as.
Then personally appeared the above named Robert F. Cormier,Chief,Production
and REO Branch who is personally well known to me and known to me to be a duly
appointed Chief,Production and REO Branch,FHA Field Office, Boston,MA, and
acknowledged the foregoing instrument to be his free act and deed as Chief,Production
and REO Branch,FHA Field Office,Boston,Massachusetts,for a me.n behalf of Henry
G. Cisneros,Secretary of Housing and Urban Developme;
ry Public
My commission expires:
fl 1.VlOtO tOff PUBLIC
MTM pfa55a6HH5FTTk
10 COMl O Mat 67'4Y
The foregoing is a true copy of the record In
13ook `/ qa"2,page j2 c( ,of the Hampshire
County Registry of Deeds.
Date
ATTEST:
RLarnncf. Or. CCU tafa /
REGISTER
mt.950019092 OR i Bares 15:*
Tsg
Beginning at the northwesterly corner of the granted premises
on said Meadow of one Charles Road nslow(( thenceins• southerly directionralong ethe
land of said Winslow one hundred thence easterly feet
to
or formerly of Joseph
Jo Jr.; thence Easterly along other
now or formerly for e[ yOofpsad Joseph Murray, Jr., in a line parallel
land now or th ely line of said Meadow Road seventy-five (75) feet
with the northerly of
sod Joseph thence Jr.. inyaa line parallel with the first line now or
said noeepc Murray, 135 feet to said meadow
Road; dente We one y on rsaidwMeadowiRoad seventy-five (75)Road; tplace Westerly
to the place of beginning.
MIST, WAMPSR121./.isi ee(.e(1m(W(w4EIGIStEE
w.JWNI L. DOROSME
Erlain
;rnt
42
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton,MA 01060
(413) 587- 1214TEL
(413) 586- 1264FAX
SEPTIC SYSTEM REPAIR PROGRAM
MAP OF PROPERTY FROM ASSESSORS OFFICE
PLEASE ATTACH COPY OF ASSESSOR'S MAP TO THIS FORM.
CITY OF NORTHAMPTON
BOARD OF HEALTH
210 Main Street
Northampton,MA 01060
(413) 587 - 1214 TEL
(413) 586- 1264 FAX
Er am
se A r SEPTIC SYSTEM REPAIR PROGRAM
NGINEER or REGISTERED SANITARIAN PRICE QUOTES
ITT LOCATION:
OF OWNER(S):
,flowing information is required. You must contact three (3) engineers or registered
rians to get prices on designing this
evaluation pt
system.os ice needs to include backhoe
work and
Price
MPANYNAME_ v— "— Quote
DRESS: -
ONE NUMBER:____ _
HO YOU SPOKE WITH:
OMPANY NAME:
DDRESS:______
HONE NUMBER:
HO YOU SPOKE WITH:
Price
Quote
Price
OMPANY NAME: _ ' Quote
• DDRESS: ---��
HONE NUMBER:_____
HO YOU SPOKE WITH:
COMPANY NAME:
ADDRESS:_______—PHONE NUMBER:
WHO YOU SPOKE WITH:
COMPANY NAME:
ADDRESS___
PHONE NUMBER.
_____
WHO YOU SPOKE WITH:
PLEASE CHECK WHICH ENGINEER or SANITARIAN YOU PLAN TO USE.
Price
Quote
Erlain
gent
1B
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
2TY LOCATION:
OF OWNER(S):
owing Information is rites on septic system nstallllat on costs. Price needs to include construction work to
required to complete installation in accordance with approved design plans.
OMPANY NAME: ---
DDRESS: _
HONE NUMBER:
HO YOU SPOKE WITH:
Price
Quote
OMPANY NAME:
___-
DDRESS:______.
HONE NUMBER:
HO YOU SPOKE WITH:
Price
Quote
Price
OM_P_ANY NAME_ —_ E Quote
DDRESS: _—_--—�1111�l7P-
HONENUMBER: __—_
HO YOU SPOKE WITH:
COMPANY NAME:
ADDRESS:
__--___--
PHONE NUMBER:____
WHO YOU SPOKE WITH:
COMPANY NAME:
ADDRESS:
PHONE NUMBER:
WHO YOU SPOKE WITH:
EASE CHECK WHICH CONSTRUCTION CONTRACTOR YOU PLAN TO USE.
Price
Quote
Price
Quote