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661 Title 5 Witness 2017.10-HAMA-pc. CITY of NORTHAMPTON PUBLIC HEALTH DEPARTMENT Public Health Director—Merridith O'Leary gu Municipal Building-212 Main Street-Northampton, MA 01060 Phone(413)587-1215-Fax(413)587-1221 http:/intiww.northamptonma.Qon/245iHealth Application for Witnessing Official Title 5 Inspections /21 17 Fee:$150.00 (2 hour field);$75/hour thereafter S332 Date: 1617/P; ©/7 Site Address: 6.6 g.g7,1Parcel # a Pro Owner: Ac,��cl-¢- � L /J.-2�.Piu-- Property property Owner Address: 6'6/// Telephone: y/�- n Cell: Title 5 Inspector lame of Inspector /dM �� '&I-�- License #: 3 C.) company Name hid lu.e Mailing Address y*, e Sj City/State/Zip Code j 1 i / t't S .4; r Telephone: Office: / Cell: / - 62g— Please Please answer the following: Yes No: T5 Inspector has most recent plans for system to be inspected Ye- /No: 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: P2994.17--e04-621 La_EZZ, c Date requested for Inspection: 'CV-2 / 7 Time: 2'; 44- 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 ‘,-,z0,4 „. .-z. .)",..`d 1 CITY of NORTHAMPTON PTON, 4.'i71��t 1. 'M6�i : � PUBLICDEALT�DEPARTMENT TME N T4)J40Ar-_-•.� public Health Director- Merridith O'Leary "` Municipal Building-212 Main Street Phone(413)581215-Fax(413)587-1221,MA 01060 http://www.northamptonma,goy/245/Health CERTIFYING TITLE V INSPECTION Date of Inspection: r Time /'Yf Property Owner: , �. t Location of Title V Inspection: i, J Title 5 Inspector: License#: ��ST _.. Phone#: d8- �� :peteC k5/4 6/4 4 .___:____ 0 k; cis •>F�e� 3 . • • . ,V6;/47e okJ/vet- COMPONENTS IDENTIFIED: 5.'-.'144 ''' 4� • BUILDING SEWER: I I 5 • • • SEPTIC TANK: `�� - • Yes . NolL..Liquid level below the outlet/invert., 0..3. Yes No/Evidence ofbackgp Yes---,- No. Sludge depth and.thickness (Within 12 inches of outlet tee-pumping recommended) )-BOX: ,4� 'esNo Static water level is at or higher than invert of outlet pipe Q/c 'es NoBroken box,obstructed pipe,or box is uneven or settled es V No D-box is level and flow is equal es No Evidence of solids carryover /5-X2d SAS: Yes,4 No — Leaching system located [ k7T/ Yess —No Portion of the SAS exposed to determine condition , 5A 5 : .tet �7�� Yes __ — No Evidence of breakout,ponding,or sewage backup Yes NoX.Leaching pit/Cesspool PUMP CHAMBER: . Yes No Alarms and pumps functioning correctly Yes No Does system include a siphon CESSPOOL/ IVY: NOTE:CESSPOO '0 BE PUMPED AS PART OF INSPECTION GREASE TRAP lGHT TANK: NOTE:TANK MUS E PUMPED AS PART OF INSPECTION GROUNDWATER DETERMINATION: Met I ods of estimating ,GH :rows I wa er elev.ti 1 n: ' / . A �, - I4 4 f e / -` Ar.. 4 Yes NoLocation of bottom of leaching facility compared to the HIGH groundwater elevation p com leted? ` �� (' iso CONDITIONALLY PASSES — FAILS — FURTHER.EVALUATION NEM{ '' _.'' --------ree--/- 05:// 7 Signature of Board of Health Agent Da