348 Title 5 & Perc Applications, Inspection & Soil Eval 2020CUT Of N®RTHAMPT®N 44D
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PUBLIC HEALTH DEPARTMENT t16-0
Public Health Director - Merridith O'Leary
Municipal Building- 212 Main Street Northampton, MA 01060 (a4rl
Phone (413)587-1215 - Fax (413)587-1221
htd)://wu•iv.northantimoamm. i,,od245/Fleatth 1/1C
Application for Witnessing Official Title 5 Inspections
Fee: $150.00 (2 hour field); $75/hour thereafter
Date:e
Site Address:
Property Owner:
Parcel #
Property Owner Address: �✓�Iv/L
Telephone: / �`/' gy 5 O Cell: N�17
Title 5 Inspector
Name of Inspector
Company Name
N/1�%7 %3/2�aCc z License #:
✓.z%Lc <S NS/>C C%7oiU Sc'i2L TCt=
Mailing Address / ,516NY 17'j-1 L /261)/)
City/State/Zip Code
Telephone: Office: SSS " / S// Cell: o)L S Sx Y
Please answer the following:
Yes / 1No:1 T5 Inspector has most recent plans for system to be inspected
YesNo: 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:
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Date requested for Inspection: 70e SDl % !i- o .J dkx Time: x db/d• m
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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
Date of Inspection:
Property Owner:
CITY 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
http: //www. northamptonma.gov/245/Health
CERTIFYING TITLE V INSPECTION
old l Time:' oV�r^q
Location of Title V Inspection: _ -rzz asd L- //� �
Title S Inspector:!7 f/ �j�t c 9 C C
License #: ✓C y��z
Phone #: /' z//3 - 599 y
COMPONENTS IDENTIFIED: 7 410 X
BUILDING
/1 PV Z
SEPTIC TANK:,5 d°�• � jZi0,X-1
Z ' 5c'4= 5a L i "-'
Yes No -/—N Liquid level below the outlet/invert
Yes No_x_ Evidence of backup
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Yes No Sludge depth and thickness (Within 12 inches of outlet tee - pumping recommended)
D -BOX : /-/ ."-1
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Yes 11'� No 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 i D -box is level and flow is equal
Yes No Evidence of solids carryover
Yes--V� No Leaching system located
Yes No Portion of the SAS exposed to determine condition
Yes—y--,,No Evidence of breakout, ponding, or sewage backup
Yes No 1-- Leaching pit/Cesspool
PUMP CHAMBER:
Yes No Alarms and 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:
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Yes 'V No Location of bottom of leaching facility compared to the HIGH groundwater elevation
completed?
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City"of Northampton Board of Health
212 Main Street
Northampton, MA 01060
L 413-587-1214
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Fee Collected: ` cgnY ec � )
Pere Test Date:
APPLICATION MUST BE SUBMITTED I® BU
Property Address:
Owner's Name:
Date://r �' •�
Performed by:
S`
Witnessed by:?1 a
No. of Bedrooms: 4
Garbage Grinder? _
Fee Paid? . Yes
CITY 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
http:/hvww. na•thamplontna.gov/245/Health
Perc Test/Soil Evaluation Form
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Rate (min/in)
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Deep Hole Observation Log
Depth From
Soil Horizon
Soil Texture
Soil Color
Mottling
Surface (inches)
(inches)
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