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Home My WebLink AboutCertificate of Compliance - 115 LACONIA CIRCLE 5/9/2016 ® S�T'LLED1Gg6 1 y PUBLIC HEALTH DEPARTMENT Town of Forth Andover Community Development Division ERTIFIC-1ATE OF As m 5/9/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D-Box By: John DiVincenzo At 115 Laconia Circle Map 105.D Lot 0137 North Andover, MA 01845 The:Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. r Michele Grant � .Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web wmdownof north an dove r.com e ° • North Andover Health Department Community awl Emiomir Development Division QN ITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 115 Laconia MAP: 105.D LOT: 0137 INSTALLER: John Divincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-box INSPECTION: 5/9/16 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base X H-20 D-Box X Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) X Schedule 40 PVC Pipe Comments: Commonwealth of Massachusetts Map-Block-Lot '� • 105.D0137 BOARD OF HEALTH - -- -- Permit No------------ • North Andover BHP-2016-0136 - P.I. FEE F.I. $175.00 DISPOSAL WORKS CONSTRUCTION I'T Permission is hereby granted John D1Vincenzo to(Repair)an Individual Sewage Disposal System. at No 115 LACONIA CIRCLE —- -K as shown on the application for Disposal Works Construction Permit No. BHP-2016-013 Date 05,_2016 Issued On.May-05-2016 BOARD OF HEALTH Il� tuon for Septic Disposal S y tem - --- Construction Permit — TOWN OF TODAY'S DATE $350.00-Full Repair NORTH V . 01845 $175.00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use Repair or replace an existing on-site sewage disposal syste only the tab key Repair or replace an existing system component—What? to move your cursor-do not use the return A. Facility Information key. ss o�6 —Add L -- — # "2, nt -- City/Town rere� 2.-*TYPE ®F TIC SYSTEM*: k'V ' Y ❑ Pump Gravity(choose one) ***If pump system, attach copy of electrical permit to application*** TOWN U N iR n i A iI °)V Y Y ® Conventional System (pipe and stone system) )fl it/V i DET1,8J-0 i EN i Y ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) ❑ Pressure Distribution S.A.S.(No D-Box) Y ❑ Pressure Dosed(D-Box Present)S.A.S. Y ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) WW hatis the Malce? _What is the Model.__ 2. Owner Information Name * Address(if different from abo)v ) /ti,' ! rL6 it �( City/Town State Zip Code Email address Telephone Number 3. Installer Information t /— L t /��+ - �r � � - Name� I �// q (f Name of Company AddR c, City/Town State _ Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town -- State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Application for Slel tic Disposal System Construction Permit — TOWN F TODAY'S BATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component PAGE 2 OF A. Facilitv Information continued.... 5. Type of Building: JResidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme tal Code, as well as the Local Subsurface Disposal Regulations for the Town of Nort n ve . 1 erst rrd that until a final Certificate of Compliance has been issued by this o d o e h th installed system is not approved. e Date Q___. Ap�►i�tn Appro (Board of Health Represent9�r = A - a e Date A plicti n Disapproved for the fallowing reasons: For Office Use Only: 1. Fee Attached? Yes LZI No 2. Project Manager Obligation Fotm Attached? Yes No 3. Putnp System? If so,Attach copv ofE •ti calPetmit Yes No Applicant received copy of "Electrical Inspection Notes far Septic Sys te s" Yes No Handout? 4. Reviewed approval letter, all papeavotkreceived? es_ No Missint; S. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6: Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit-Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (address of septic system) For plans by Relative to the application of ( % i ��/ Lz Gy) ('histaller's name) And dated Dated •.�,. J rrgma date) odaysdate With revisions dated (bast re6scd date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans pnor to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (1") inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OIL (or e-snail to: lrt;l(h.drtC�1t()wii(.)frtortli,,iti loN7er.coi.ii) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer inust be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than lily ple excamliolr�and I am requited to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover:, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Detetrnination that the proper elevation of the excavation has been reached b. Inspection of the sand and stone to be used c. Final inspection by Board ofl-Jealth staff or consultant. d Installation of tank, D-Box,pipes, stone, vent,pump chamber,retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved eded plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (":l'oda is I1,te) a _ Name:. Print) Nairttc._..Srgtae.c