36 Title V Application & Certify Inspection, notesi�1ts�w
CITY gf'NORTHAMPTON «
t'CIBLIC �"'L�IL'I"i DEF9R7:1 EVE Y�G
Public lieafth Director -- rifer°rrtiith O Leaty
kfnsicipal Building —212 kfain StreeI —A'odhanrpPon, 3I224 01060
Phone (413)537-1215-n1*ay (413)58712-11
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Application for Witnessing Official Title 5 Inspect:ion.5
Fee: 5'150,00 (2 hour field); S75/hour thereafter
Date: 10/15/20
Site Address: 36 Sovereign Way Parcel #
Property Owner: John bran CL.m
Property Owner Address: 36 Sovereign Way
Telephone: Cell: 203-410-4451
Title 5 Inspector
Name of Inspector Raymond Mieczkowski License #: 2720
Company Name Systems
Mailing Address 54 Comins Road
City/State/Zip Code Hadley, MA. 01035
Telephone: Office: n/a
Please answer the following:
Cell: 413-374-0483
ED' No: T5 Inspector has most recent plans for system to be inspected
YeS 1 No: T5 Inspector has pump -out records
Yes G>5 Inspector has location of private water supply wells (within 150 feet of system location)
Reason for Inspection:
Home being sold
Date requested for Inspection:
ASAP
Time: Afternoon
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 NORTIIAMPTON
Application Fee is Non-Relundeble
CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
Public Health Director — Merridith O'Leary
Municipal Building - 212 Main Street - Northampton, MA 01060
Phone (413)587-1215 - Fax (413)587-1221
http: //www. northamptonma.gov/245/Health
CERTIFYING TITLE V INSPECTION
Date of Inspection: t'�> i' �--V Time: q, 1V" (' d A�
Property Owner:
Location of Title V Inspection: 9G- IVY I/
Title 5 Inspector: L'4 J,7.o>v b "J'a" �"6
License M fQ J%�®
Phone #:
COMPONENTS IDENTIFIED:rDP r<. 1�9s4��9r1?_• ���
BUILDING SEWER:
SEPTICTANK: `�Grr�� `ct2/2e<ARJC`C�[:q c
Yes No/ Liquid level below the outlet/invert
Yes No + Evidence of backup
Yes No Sludge depth and thickness (Within 12 inches of outlet tee - pumping recommended)
Yes No `'� 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 t� No D -box is level and flow is equal
Yes No P' % Evidence of solids carryover
Yes ✓ No Leaching system located
Yes No Portion of the SAS exposed to determine condition
Yes No I Evidence of breakout, ponding, or sewage backup
Yes No Leaching pit/Cesspool
PUMP
Yes Vz- No Alarms and pumps functioning correctly
Yes i`� No Does system include a siphon
CESSPOOL/PRIVY:
NOTE: CESSPOOL TO BE PUMPED AS PART OF INSPECTION
GREASE TRAP/TIGHT TANK:
NOTE: TANK MUST BE PUMPED AS PART OF INSPECTION
GROUNDWATER DETERMINATION:
Methods of estimating HIGH groundwater elevation:
Yes No Location of bottom of leaching facility compared to the HIGH groundwater elevation
completed?
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Nora pion
Fw: Risers installed at 36 Sovereign Way.
1 message
Dennis Lacourse <dennislacourse@hotmail.com>
To: Kelly Constantine <kconstantine@northamptonma.gov>
Hi Kelly,
Please print and put in that file.
Thanks
Dennis
From: Ray Mitch <raymitch54@gmail.com>
Sent: Friday, October 30, 2020 1:49 PM
To: Dennis Lacourse <dennislacourse@hotmail.com>
Subject: Risers installed at 36 Sovereign Way.
Dennis -
All installed. (3) 6" on the Tank and a 12" on the pump chamber.
All with magnetic tape.
-Ray
7 attachments
Kelly Constantine <kconstantine@northamptonma.gov>
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