820 Title 5 Form 2019 CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
1 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:
Property Owner
Location of Title V Inspection: 9a0 N K p`h `
Title 5 Inspector �r � �►:V1 y , £
License#:
Phone#: 413'S'-)7L 4Y® '
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COMPONENTS IDENTIFIED: S j?+1 Z., .k 4- ( 'Q C ►h 1 R 1'
BUILDING SEWER: I1�' LLA �f�� f '�"� % ,0�� SQA t �►�1
SEPTIC TANK: ow N ons _ n
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Jo n 1< kCL 10 v g ifons
3
Yes No Liquid levelbelow--theutlet/mv rt (
r Rau a f` 3 sa
14,
Yes I�o r Evidenc&,p-ft aEckup � � }
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Yes... No Sludge depth and thickness (Within 12 inch s of outlet to pumping recommended)
JUL 11 L L
3-
D-BOX:
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Yes No Stati water le el is at or higher x an inv rt of outlet pipe`
Yes No Br,ken box, ob tructed pipe, 'r box is un ven or settled
1
Yes 10 -box is level an flow is e, al
Y No\ Evidence of solids arty er
SAS: Ifachinq qj-1 pc)3s, biq in h t to . - y r om dtC C
bt 1 l°;j a ( ckqs 0. ole- L r` rm �W j
Yes V No Leaching system located
Yes No Portion of the SAS exposed to determine condition
Yes No Evidence of breakout,ponding, or sewage backup Set c-b iD &,4-9 0
Yes ✓ No Leaching pit/Cesspool
PUMP CHAMBER: J a -
Ye/ No Ala s and pu nfunct ning correct Y
r
es o Does s include a siipho
CESSPOOL/PRIVY:
NOT : CESSPOOL TQBE PUMI,ED AS PA NSPECTION
ha "r
:
A �..
4
GREASE TRAP/TIGHT TANK: _
NOTE:TANK
/IyI�E PUMPED AS PLS INSPECTION
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GROUNDWATER DETERMINATION:
Methods of estimating HIGH groundwater elevation:
S -.hX)y.-, U i�►'
In q
E 7 d 41 3
oLpcation of bottom of'leacliing faci�ty compared to theIIGH groudwter 1 vation
coml7leted?
11
PASSES,
. D'PASSES w „AILS xtiFC1TIReEUALATr;ON;NEEDED
Signature of Board of Health Agent Date