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Home My WebLink AboutCertificate of Compliance - 217 GRAY STREET 5/13/2016 • • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 5/13/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Full replacement of an On-Site Sewage Disposal System By: Todd Bateson At: ray Street Map 107D Lot North Andover, MA 0184 Jl e Issuance o . is ertificate shall not be construed as a guarantee that the system will function satisfactorily. Au Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com a ry e N �N / � 1 PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM -- INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( )constructed; (01 repaired; �°°�°°dd ' A J (Print Name) - Located at: - (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan,originally dated and last revised oil 3 �2.0114 with a design flow of ---- -- -- i — gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310. CMR 15.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the I3oard of Health, Q � Bottom of Bed Inspection Date: — Engineer Representative(Signature) And--Print Name ] A Final Construction Inspection Date:___L 9 � l�,nl iaxeer Representative(Signature) And--Print Name Installer: Q t a"� (Signature) Date: � And Print Name E ngineer:. (Signature) Dater ( t .......... 1600 Osgood Street, North .Andover, Massach etts 01845 Phone 978.688.9540 Fax 970,666.0476 Web http://www.townofnorthandover.com Commonwealth of Massachusetts -- City/Town of Nov d , _ -- Certificate of Compliance Form 3 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. This is to Certify that the following work on an On-Site Sewage Disposal System Important: When filling out ❑ Construction of a new system forms on the I Repair or replacement of an existing system computer,use ❑ Repair or replacement of an existing system component only the tab key to move your cursor-do not Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): use the return key. DyyS��CP Number DSCP Date Facility Owner Street Address or Lot# City/Town State Zip Code Designer Information: G' Name me Na � meofCompany ...( Signature Date Installer Information: Name Name of Company Signature Date _ Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Approving Authority - - -- — - Signature Date ----- t5form3.doc-06/03 Certificate of Compliance•Page 1 of 1 Town of ver — Septic System - AS-BUILT CHECKLIST 1) V All changes to the design plan have been reflected and noted on the as-built plan FF 2) v As-built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans) 3) Street Address,Assessor's Map and Lot Number 4l) ` Lot Lines and Location of Dwellings served by the system 5) 1 Locations,Elevations and Dimensions of As-built system components,including reserve (if applicable) /' 0 6) Ties to all tank openings,d-box,and leach area from dwelling or Permanent Structure 7) Setback distances are shown on the as-built plan from system components to; Subsurface,interceptor&Foundation drains � Catch basins \, Property fines Dwellings or or other structures . 11// Private water supply or irrigation wells ) E Watercourses or wetlands 8) Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system 9) Location of water,gas,electric lines,cable,control panel (if applicable) 10) Location of Structures within 6 Inches of Finished Grade 11) Original Stamp&Signature 12) Location and holder of any easements which could impact the system 13 Impervious envious Areas Drive ) � p , � ays,etc 14) North Arrow F, 15) V/ ocation &Elevation of Benchmark used 16) t STATEMENT ON PLAN (NA 5.3) a. "1 certify the locations, elevations; ties, cover material;exposed component covers etc., shown on this as-built substantially agree with the approved plan and have determined that the break out elevations,if applicable,have been met." Signature of Designer Date b. "If a STUCTURAL WALL IS PRESENT(NA 4.9)a Letter or statement oil the as-built irrdicatin� the wall- was or was not constructed in accor dance with the intended design and an y manufacturer's specifications." Signature of Designer Date Revised 3/17/15 North Andover Health Department Community and Economic Development Division QNSITE WASTEWATER fro T M CONSTRUCTION N T LOCATION INFORMATION ADDRESS: 217 Gray St. MAP: 107D LOT: 112 INSTALLER: Todd Bateson DESIGNER: LJR Engineering PLAN DATE: 8/14/14, rev. 9/23/14 BOH APPROVAL DATE ON PLAN: 10/9/14 INSPECTIONS TANK INSPECTION: 8/26/15 DATE OF BED BOTTOM INSPECTION:8/26/15 DATE OF FINAL CONSTRUCTION INSPECTION: 9/2/15 DATE OF FINAL GRADE INSPECTION:10/27/15 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: New septic tank and pump chamber were installed instead of using the existing tanks. SEPTIC TANK ® Building sewer in continuous grade, on compacted firm base N/A 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 Z Inlet tee installed, centered under access port ® Outlet tee installed, centered under access port (effluent filter) ® 24" inch cover to within 6" of finish grade installed over one access port ® Neoprene boots around inlet & outlet Comments: PUMP CHAMBER ® Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1000 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 ® 24" cover at final grade installed over pump access port ® Water tightness of tank has been achieved by Visual testing ® Neoprene boots 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 ® H-20 D-Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N/A Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: 28x42 with overdig SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ® Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ® Number of chambers per row: 8 ® Number of rows (trenches): 5 Comments: Total Chambers = 40 FINAL GRADE X Loamed X Seeded X Cover per plan Comments: DOCUMENTS NEEDED Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer X As-Built Plan BM = 88.24 HR = 3.68 H I = 91.92 SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark At cast iron Building 6.38 85.19 85.42 Sewer OUT Septic Tank IN 6.46 85.11 85.27 Septic Tank OUT 6.75 84.82 85.13 Pump Chamber IN 7.12 84.45 84.25 (2")Pump Chamber OUT 6.92 84.83 ----- (2")Distribution Box IN 5.28 86.47 86.42 (4")Distribution Box OUT 5.30 86.27 86.25 Lateral 1 TOP 5.38 Lateral 1 INVERT 86.19 86.17 Lateral 2 TOP 5.40 Lateral 2 INVERT 86.17 86.17 Lateral 3 TOP 5.40 Lateral 3 INVERT 86.17 86.17 Lateral 4 TOP 5.40 Lateral 4 INVERT 86.17 86.17 Lateral 5 TOP 5.40 Lateral 5 INVERT 86.17 86.17 Top of Chamber 5.40 86.52 Bottom of Bed/Chamber 85.52 85.5 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Bank 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). '.... 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Tomm of North Andover ® Septic System - AS-BUILT CHECKLIST 1) All changes to the design plan have been reflected and noted on the as-built plan 2) As-built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans) 3) t Street Address,Assessor's Map and Lot Number 4) `� Lot Lines and Location of Dwellings served by the system 5) J Locations,Elevations and Dimensions of As-built system components,including reserve (if applicable) 6) Ties to all tank openings,d-box,and leach area from dwelling or Permanent Structure 7) Setback distances are shown on the as-built plan from system components to: tj/Ot Subsurface,interceptor&foundation drains Catch basins 7—Property lines �"\1, Dwellings or other structures (� 4 Private water supply or irrigation wells U 01"Y'r!(fl I"KY, !" Watercourses or wetlands 0) Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system 9) J Location of water,gas,electric lines,cable,control panel (if applicable) 10) Location of Structures within G Inches of Finished Grade 11) Original Stamp&Signature 12) Location and holder of any easements which could impact the system 13) Impervious Areas;Driveways,etc 14) North Arrow 15) Location &Elevation of Benchmark used 16) STATEMENT ON PLAN(NA 5.3) a. "I CelYlfy the I0Ca6011s, Clevat1017s, ties, COvei,jnatei4alj exposed Con1porient COVCI:S etc., shawl?017 this as-buuilt substal7ti"111yagive i-vith the approved plan a11d have determined that the breal Out elevati011s,if applicable,have heel?met" Signature of Designer Date b. "Ifa ST UC'TURAL YhAIL IS PRESENT(NA 4. a Letter ahstatem oil t on the as-hi ilth7dicatij .the wall- was, oh was slot constrlleted in accoi dance with the intel7ded design and any 171an1113C Ill^er V spaecifica60l7s." Signature of Designer Date As of:Tuesu-;y,March 17,2015