1051 Title 5 Application & Certify Inspection 2020CITY 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
hitp:llwww. northamptonma.gov/245/Health
CERTIFYING TITLE V INSPECTION
��d 4
�Date of Inspection: //W , d
Property Owner: �1�' e 9s%� a ✓
Location of Title V Inspection:
Title 5 Inspector: 4V
License #:
F
Phone #:
COMPONENTS IDENTIFIED:
BUILDING SEWER: (' w<„,
1i
No Liquid level below the outlet/invert
Yes V No Evidence of backup
N
Yes No Sludge depth and thickness (Within 12 inches of outlet tee - pumping recommended)
Yes / No N/d Static water level is at or higher than invert of outlet pipe
Yes___{_ No "' t Broken box, obstructed pipe, or box is uneven or settled
Yes / No*
o D -box is level and flow is -equal
Yes V No Evidence of solids carryover
i`
Yes No Leaching system located
Yes—Z No Portion of the SAS exposed to determine condition
Yes—k�— No Evidence of breakout, ponding, or sewage backup
Yes No Leaching pit/Cesspool
PUMP
Yes No Alarms nd pumps functioning correctly
Yes 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:
go
Yes No Location of bottom of leaching facility compared to the HIGH groundwater elevation
completed?
CITY of NORT A4 MPT N
PUBLIC HEALTHDEI'ARTMENT 144160
Public Health Director — Merridith O'Leary
Municipal Building — 212 Main Street —Northampton, MA 01060
Phone (413)587-1215 — Fax (413)587-1221
htip://mivw.northamhtoienia.frov/245/Heattli
Application for Witnessing Official Title 5 Inspections
Fee: $150.00 (2 hour field); $75/hour thereafter
Date: It ID
Site Address: Lc Parcel # t Zi
Property Owner:
Property Owner Address:
Telephone:
Title 5 Inspector -�^
Name of Inspector I I I V1 ��@ (`� l h V-)
Company Name t1V N
Mailing Address
City/State/Zip Code
Telephone:
-30E MOY-+L�ty)&�h
Cell:. b6& _ Ci >
License #: _[ 032
Office: Cell: q � 6 5yTS Z Z3
Please answer the following:
Yes No T5 inspector has most recent plans for system to be inspected
Yes /is. T5 Inspector has pump -out records
Yes / No: T5 Inspector has location of private water supply wells (within 150 feet of system location)
Reason for Inspection: Gc.h V\q `(-ev_A, 4-D 6e_ -H p rngair+-,1
Date requested for Inspection: I�oV Time: —�Y1 1
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