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380 Septic System Repair Program 1999 (2) Peter Mariam Health Agent FORM 2 CITY OF NORTIIAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 589- 1214 TEL (413) 586- 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM MAP OF PROPERTY FROM ASSESSORS OFFICE PLEASE ATTACH COPY OF SESSOR'S MAP TO THIS FORM. A. Poe: McEd L Health Agent FORM 1 Name 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 Mailing Address. OWNER HOUSEHOLD INFORMATION M relic a(A•,4bbztCss'a,r/c °i fin y4I , Abba>eSCa, 2gi e4eslerkid Pao;d Zeta/Vim- O7' 52 Home Telephone: YW . 1q-T/'26i Work Telephone: V/';') fey_2727 B. Property Location: PROPERTY INFORMATION 8G l'hesfcf4ent cad Leeds rNig- "/052 Number of Occupants: Bedrooms: V 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 ® NO ■ IF SO PLEASE EXPLAIN BELOW. (ATTACH REPORT) E. ARE THERE CURRENTLY ANY LIENS OR ATTACHMENTS RECORDED AGAINST YOUR PROPERTY? YES © NO ■ Explanation: deV7/ }1n6IIag — ,4r ci" eg ; $22 2 eel. CO SIGNATURE OF OWNER: DATE: 7/55/'y/ Peter 1.h1[Etlain 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: 4 (V e5WrJ2 ldf ,.cam, Zeecls, AI- 0/O13 STREET: OWNER(S) OF RECORD: ADDRESS: CbesWr4'e/d P,Oad /S LOT# O// ktrehda 9-, AbbatesSa Tanyc L. Aek/SSa. 216f CheSler4e/d EOOC< ,Leads, /h, O7' 53 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 #: PAGE #: 006 yi SIGNATURE: _tat, �lii_ TITLE: /ltV erS 2ttd26,-/ ,A-. kbb cy.Q?()r• DATE: 7407 PRINT NAME: r-- � � "\� ell/O � 0 � 1 ) il(‘If � / € � � i \ —J �r e � n �@G a r �1. 111 it irk sy ,I • _ill 3TI .if..-:-.ri"..1,--71-51]._, titirtiprir., 24,•■,-,%„,,,v- EAKIV:a wirs ,4 / , '.. --,X1,1 111) se 1 17' r 7 „,,,-\.‘" —.` 1 , ,,‘ 14 A ■ 10"<---(lit- ae, ••• 1 ' ; I�l I , �)���/ ' .III,( :��i „. „ W9tVflMwAns / . , s?lire 3-� '.ic�� y�il�Ji��RlI�1 �': ae"w iii I C �l 13 1 .,, MNd ��� �" ! ; /�Iy / �� �1�N� ids. V�� I �9 /l�/ '-mil V IyyII * .. ��` // ), (E+ `4. IN it �,, IX�.. J /I 2 l\ Oft- � 1� s - ' �( .� ��N' `y. �, � r - Ai •,�/� -1 \ 1. �' / { ., ,...441.41 , * „,s___„. _ isa ' \. 7 v ��� ,mss„,,L,/,„ ,r_ .. 5 iii,s1,____} .11wetNirt,„ p' -7, 4.\ ' \t \,)% n oil ll�lJ/G �1 x. G /a i I ln � I �� � ,r�l � (, ��� �, � rte_ i —. ��.�: , . , Peter 1.Mcfilain Health Agent FORM 5 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton,MA 01060 (413) 587-1214 TEL (413) 586— 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM ASSESSOR'S STATEMENT OF VALUE PROPERTY LOCATION: .age Chester-4(d gad, Leeds /72,% STREET: e eth c/d ✓mac n _/ MAP ILOT# OWNER(S) OF RECORD: ADDRESS: fltehad A-. AktoedesSQ, cir, V rang • A-M-te,� &? &h&rker ?/d goad, lee' rn4- O/ 13 THE ABOVE REFERENCED PROPERTY IS VALUED AT S- ACCORDING TO THE CITY OF NORTHAMPTON ASSESSOR'S RECORDS. SIGNATURE: TITLE: PRINT NAME: DATE: COMMENTS Of any required): Peter;.McEriam Haiti Agent FORM 4 CITY OF NORTHAMPTON BOARD OF HEALTH 210 Main Street Northampton, MA 01060 (413) 587— 1214 TEL (413) 586 - 1264 FAX SEPTIC SYSTEM REPAIR PROGRAM TAX COLLECTOR'S CERTIFICATION PROPERTY LOCATION: 384 Cheskrgerd Q'aaa Leeds Mt STREET: e15lerCr/cl Road MAP j LOT# /5 D// OWOE(S) RECORD: A,travie/ A , 4b6,i s2 Jr "1- Tnyt 2 . //66aesse_ /ii,k ADDRESS: 2 dhes7cf ere/Raaa ,Leeds, fibr d/DSJ ITEM WATER ASSESSMENTS $ AMOUNT /CA- STATUS SEWER ASSESSMENTS ( $ /ii,k REAL ESTATE TAXES $ OTHER (Describe) I $ AV79. SIGNATURE: Tax Collector DATE: COMMENTS: THE BOARD OF HEALTH WILL NOT LOAN MONEY TO ANYONE HAVING A BALANCE DUE. 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, priv or any portion of the soil absorption system extends below the high groundwater elevation; YES DI NO 1 8. other reason(s) as to why system is no working or has failed: IS YOUR YEARLY INCOME $150,00.00 OR GREATER? YES NO I k I 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: Date: Please attach any reports you may have on this septic system. STOP- 7//5/9 9 '7/73/99 DETERMINATION BY THE BOARD OF HEALTH SIGNED: SIGNED: HH/gent Chairman, Board of Health 2 Date: 7//7 /7 / Date: Putt J.Mc Erhln 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 I PROPERTY LOCATION: ; D ehe ki-L ee if gene', ,Lee's, 0, E1" ' NAME(S) OF OWNER(S): q Abt i3 Jr J 15.303: Systems Failing to Protect the Public Heatth 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 dogged soil absorption system or cesspool; YES X I NO j 2. there is a discharge of effluent di ectly 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 3. the static liquid level in the distribution box is above the level of the outlet invert; YES j NO I 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 I I NO XI 5. the septic tank or cesspool requires pumping more than four times a year; YES I I NO 1 Pe:rrI MLElala Health AScnl FORM 8 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 PROPERTY: ! STREET: MAP LOT # OWNER(S) OF RECORD: ADDRESS: 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 J.McErbin Health Agent FORM B 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 PROPERTY LOCATION: C/rte. NAME(S) OF OWNER(S): `lZL2/ccc‘ tK / CCU cto 4/6 'SSG The following information is required. You must contact three (3) construction contractors to get prices on septic system installation costs. Price needs to include construction work required to complete installation in accordance with approved design plans. a COMPANY NAME: a Price ` ADDRESS: Quote PHONE NUMBER: a- f >."-. . WHO YOU SPOKE WITH: COMPANY NAME: ADDRESS: 1'. PHONE NUMBER: WHO YOU SPOKE WITH: COMPANY NAME: ADDRESS: Price Quote Price Quote PHONE NUMBER: WHO YOU SPOKE WITH: Price Quote PHONE NUMBER: WHO YOU SPOKE WITH: 5. COMPANY NAME: ADDRESS: PHONE NUMBER: WHO YOU SPOKE WITH: Price $ .00 Quote I PLEASE CHECK WHICH CONSTRUCTION CONTRACTOR YOU PLAN TO USE. 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- 1264FAX SEPTIC SYSTEM REPAIR PROGRAM PROJECT BUDGET PROPERTY LOCATION: scych, h/cz % 7 . /e,J, 4n- STREET: AMOUNT APPROVED BY THE BOARD OF HEALTH $ fly 47D27-' MAP - / "5 LOT# 6 r i 3 �CG� Ce_ OWNER(S) OF RECORD: il /�,, 'I,LC Q 9 A ( ��{C�ta !¢ / /la 4---S41,- ADDRESS: I .K ESTIMATED COST OF: AMOUNT APPROVED BY THE BOARD OF HEALTH $ fly 47D27-' PERCOLATION TEST & DESIGN: - .00 $ - a 2. CONSTRUCTION OF SYSTEM: $ /RI, L- l .00 SHALL BE REMAINING 50%WITHIN 30 DAYS DAYS OF LETTER OF COMPLIANCE FROM THE NORTHAMPTON BOARD OF HEALTH. .K TOTAL AMOUNT REQUESTED: $ /L/ CC, .00 STOP-- SIGNED SIGNED AND APPROVED BY: Northampton Board of Health DATE: eter McErlain, Health Agent AMOUNT APPROVED BY THE BOARD OF HEALTH $ fly 47D27-' .00 1. PAYMENT SCHEDULE: SHALL BE 100%AT COMPLETION AND APPROVAL OF DESIGN. a 2. SHALL BE 50% UP FRONT TO BEGIN CONSTRUCTION. U 3. SHALL BE REMAINING 50%WITHIN 30 DAYS DAYS OF LETTER OF COMPLIANCE FROM THE NORTHAMPTON BOARD OF HEALTH. SIGNED SIGNED AND APPROVED BY: Northampton Board of Health DATE: eter McErlain, Health Agent