428 Title 5 Application 2018 ;Ali)i �
ci
egl mP,o CITY of NORTHAMPTON L '
Oft PUBLIC HEALTH DEPARTMENT ���'
-�' .r! Public Health Director-Merridith O'Leary
attu1' in
' Municipal Building-212 Main Street--Northampton,MA 01060
Phone(413)587-1215-Fax(413)587-1221
ht(P:/H air.nonliamptonmu.eo✓245/Health
Application for Witnessing Official Title 5 Inspections
((FFLee:$150.00(2 hour field);$75/hour thereafter
Date: J lb- I U
Site Address: tt01.6 Ct ie e-cit"'
Parcel
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Property Owner: J&1✓iT*--fatrislIv1k.- in-*
Property Owner Address: 5/ 0 Si& -ilow✓)1V it#Y-e
Sin flartaTti i£1
Telephone: tugsbi-1J05
L Com^ 0: 44(of
Title 5 Inspector / • /// //'l
Name of Inspector R !/ 5-/e r,-)74-i_ / License#: -VA) 7 / t/
Company Name �O REDO/.0 0C+/Q�/J
Mailing Address 1 C�Liere l i / 4- '
City/State/Zip Code 1-17-7,/
Telephone: Office: 7
Cell:
Please answer the following:
Yes / o: T5 Inspector has most recent plans for system to be inspected
at No: T5 Inspector has pump-out records
Cr,: T5 Inspector has location of private water supply wells (within 150 feet of system location)
Reason for Inspection,
H/1oeZSP r." .54./e
Date requested for Inspection: 5/4/ Time: /q
' 3O4M
Return Application Ten Days Prior to Requested Inspection Date to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
MAKE CHECKS PAYABLE TO THE CITY OF NORTHAMPTON
Application Fee is Non-Refundable
.,:ih,HW e�° CITY of NORTHAMPTON
i,„l PUBLIC HEALTH DEPARTMENT
i' _-
$� 5 Public Health Director-Merridith O'Leary
N•5014--'=gb
Municipal Building 212 Main Street Northampton,MA 01060
Phone (413)587-1215 Fax(413)587-1221
httpillwww.northamptonma.gov/245/Health
northamptonma.gov/245/Health
CERTIFYING TITLE V INSPECTION
Date of Inspection: S/e" tr( Time: 7 130 4 M
T 1
Property Owner: ---.1 e••JN 1 -LC�_1l �"�r-; 15l, 1-0 r 'YI�C' I r�S�J
Location of Title V Inspection:lL4 d-g CLe. S-- (-Cie `J Pc"
Title S Inspector: i l l c i e(-JI TC.
License#:
Phone#: IJ9C S cr•e Me.S
5ctL l c eSco C4 3 ,
9 'El a7
COMPONENTS IDENTIFIED: CC be>guCL
BUILDING SEWER:0 K
SEPTIC TANK: c.. P roe as s -C ai nite r
"rrs ' - o -
Yes No / Liquid level below the outlet/invert
Yes /_ No X\ /Evidence of backup
Yes_ No ><Sludge depth and thickness (Within 12 inches of outlet tee-pumping recommended)
)6-BOX) , i c OO 4--y' UC �..: q.r
Yes_ No X Static water level is at or higher than invert of outlet pipe
Yes No Broken box,obstructed pipe,or box is uneven or settled
Yes X No D-box is level and flow is equal
Yes No )(Evidence of solids carryover
SAS: C K
Yes V No Leaching system located
Yes No Portion of the SAS exposed to determine condition
Yes No Evidence of breakout,ponding,or sewage backup
Yes No74 Leaching
//p p�it/Cesspool/'t
PUMP CHAMBER: IJ / -
Yes No Alarms and pumps functioning correctly
Yes No Does system include a siphon
CESSPOOL/PRIVY:
NOTE:CESSPOOL TO BE PUMPED A PART OF INSPECTION
KVA
GREASE TRAP/TIGHT TANK:
NOTE:TANK MUST BE PUMPED AS PART OF INSPECTION
rJ /A N
GROUNDWATER DETERMINATION:
Methods of estimating HIGH groundwater elev do (
c�P2 G.r, IP —cto, Cs SOs f® c't,4
- Sir ni_, -r-S.,. -s S' CD.-'r4 ,�z,k5 `�
Yes X No Location of bottom of leaching facility compared to the HIGH groundwater elevation
corn eted?
�� ,+a)r . `t�c7n�s- 1 I SSS
:'rri CONDITIONALLY PASSE - - FURTHER EVALUATION NEEDED
� X ci -L0 € sercL, I , L tieeJ
`N� 13ee cite lie
Signature of Board of Health Agent rep(�� Date
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