1006 Title 5 2017 (2) T,M Mp esti., CITY of NORTHAMPTON
e„.4•I .. PUBLIC HEALTH DEPARTMENT
' �� ,44p
`� Public Health Director Merridith O'Leary
°a'-"� " Municipal Building—212 Main Street—Northampton, MA 01060
Phone (413)587-1215—Fax(413)587-1221
http://www.northamptonmagov/245/Health
CERTIFYING TITLE V INSPECTION
Date of Inspection: g /D 1 1Time: �/4 't/j
Property Owner: _ /. `/ Co irk,
Location of Title V Inspection:
— /40 .• g• --mac e
/ -�AltAPTitle 5Inspector: ��� ���� �-J. r� Zee-ie
License#: 3 7-- —/g4
Phone#: 6a?8: �S3
COMPONENTS ID NTIFIE 0: I ' I . c Ar /V♦ / 1
Amimmonomrairsr
BUILDING SEWER: — Ale4iJ. 07.e7it/s'jjj^c, - r.., ti - - / c:14
SEPTIC TANK: —/4 OLJ �i,.9
J ✓
(Yes
` X Liquid level below the outlet/invert
4,0
X es,I o X Evidence of backup D' ' ��SUP.S
Yes No X Sludge depth a thickness (Within 12 inches of outlet tee -pumping recommended)
(40 i< —-) . 1it)/7 al . /
D-BOX: 'Ajec& (vu v' -�a/v o 74 /"a.i ed - - _ _ - ,. f
Yes No V 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 No VD-box is level and flow is equal
Yes No VEvidence of solids carryover
SAS: 4 �f,S -1 °C/
Yes V No Leaching system located
Yes No /Portion of the SAS exposed to determine condition
Yes No X Evidence of breakout,ponding,or sewage backup
Yes. No x Leaching pit/Cesspool
PUMP CHAMBER: 5-f4J(/'f
Yes tr....No Alarms and sum•s 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
4)/91
GROUNDWATER DETERMINATION:
Methods o estating HIGH groundwater elevation: / /7 /.45/0
!S . �'S• h
�l�l ONt o e5 1Je/e'
!iv P7-7-771/
Yes % 9 No Location of bottom of leaching facility compared to the HIGH groundwater elevation
completed?
PASSE - CONDITIONALLY PASSES - FAILS - FURTHER EVALUATION NEEDED
g iD � 7
Si • . ure of Board of Health Agent D to