327 Title V Application and Inspection 5-21-19CITY 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.northaml2tonma.zovl245II-lealth
Application for Witnessing Official Title 5 Inspections
Fee: $150.00 (2 hour field); $75/hour thereafter
Date: `z � Oma_
Site Address: `3 z
Property Owner: ., 4161-edlA
Property Owner Address: , -?a7
Telephone: 'l113-696- x/38
Title 5 Inspector
Name of Inspector
Company Name
Mailing Address
City/State/Zip Code
Parcel #
Cell:
7 m Xe/Je- License#:
011A9
Telephone: Office: v Cell: y3 v 6 a Jf-
Please answer the following:
es No: T5 Inspector has most recent plans for system to be inspected
Yes/No: T5 Inspector has pump -out records
Yes / No: T5 Inspector has location of private water supply wells (within 150 feet of system location)
Reason for Inspection:
house is Jein9 s�/�
Date requested for Inspection:
Time:
Return Application Ten Days Prior to Requested Inspection Date to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
MAKE CHECKS PAYABLE TO THE CITY OF NORTHAMPTON
Application Fee is Non -Refundable
CITY of ORT A MP TON
PUBLIC HEALTH DEPARTMENT
Public Health Director - IbMerridith O Leary
Municipal Building - 212 Main Street -.Northampton, MA 01060
Phone (4.13),187-1215.- Pax (413)587-122.1
http: //Www.northamptonma.gov/2451flealth
Date of lnspoction� S 2!
Property Owner:
Location of Title v Inspections _-- 3 2 /�IOry L, Faun f 1
Title 5Inspector, _-Tom ��-Gdt
CERTIFYING `I'ITLE,'V INSPECTION
Tirane:
✓'7� Fu ri
License #s
Phone #r. X1(3- KZ P^ c-/S?3
COMPONENTS IDENTIFIED ri ISoX . 1' 17Yl e -
BUILDING SEWER: C a -f r "ki _
SEPTIC TANK._ Soo �a ave c.yl�L -� a✓lk
Yes � _ No Liquid level below the outlet/invert.
Yes No k Evidence•ofbackup
Yes No i . Sludge depth and thickness (Within 12 inches of outlet tee - pumping recommended)
D -BOX :,T /I(+n { l �►t�Oc c tG� 4b &C (1 ac t
Yes_____. No-�- Static water level is at or higher than invert of outlet pipe
Yes % NoToken ox, obstructed pipe, or box is uneven or settled
Yeses_, No D -box is level and flow is equal
Yes -$—No Evidence of solids carryover
I
No, Leaching systern located
YC -5-- No --A-- Portion of the SAS exposed to determine condition
ycs--= Noe %�..- Evidence of breakout, pondin& or sewage backup
Yes--- No._ &- Leaching pit/Cesspool
PUMP CHAMBER:
No --V-. Alarms and pump -iorling correctly
cl
Yes,,— No Does system incl 9cullLphon
CESSPOOL/PRIVY:
NOTECESSPOOL TO BE PUMPED AS PAIZA017 INSPECTION
GREASETRAP/TIGHTTANK:
NO,rE: TANK Muss BE PUMPED AS PA14rr OF INSPECTION
GROUNDWATER DETERMINATION:
Methods Ofes I'mating II GH groun water elevation:
Yes -4k— No,----. Location of bottom of leaching facility compared to the HIGH groundwater elevation
completed?
CONDDIIONALLY PASSES - FAILS — FURTHER EVALUATION NE:DED
%gnature of Board of Health Agent Date