HomeMy WebLinkAboutMiscellaneous - 240 OLD CART WAY 4/30/2018Cil
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A. Facility information
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2. System owner.
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RECEIVED
I JUL 14 2015
TOWN OF NORTH ANDOVER
is TOWN
DEPARTMENT
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0. Pumping Record
Date . Of Pumping Data 6 — 30 -iS
2. Quantity Pumped:
Type of system: Cesspool(s)
Tight Tank
Other (describe):
-4. Effluent Too Filter present? [] Yes d Noif
Yssawas ftcleaned?
5. Condition of System: A
System Pumped By,
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 8/12/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -box, Pipe and outlet tee
By: Chad Jablonski
At:
240 Old Cartway
Map 107B Lot 7
A North Andover, MA 01845
f
The 1'ssuance o:this cert' 1 ate sh �Ilot be construed as a guarantee that the system will function satisfactorily.
f-
Michele Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
North Andover Health Department
[ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 240 Old Cart Rd. MAP: LOT:
INSTALLER: Chad Jablonski
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION: pipe d -box T 8/12/15
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ 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
X 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
107.B011�
BOARD OF HEALTH -----------Permit No ------------
North AndoverBHP-2015-0313
-----------------------
P.I. FEE
F.I. $125.00
---- ---------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Chadh- lonski
to (Repair) an Individual Sewage Disposal System.
at No 240 OLD CART WAY 1 l
as shown on the application for Disposal Works Construction Permit No. BHP- 0115; 031 1 Dated- i July f7, 2015
---
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Issued On: Jul -17-2015
BOARD OF HEALTH
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Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
learn
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Application for Septic Disposal System 7 16
Construction Permit -TOWN OF TODAY'S DATE
NORTH ANDOVER, MA 01845 Full Repair
$125. omponent
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
�
Wepair or replace an existing system component — What?
A. Facility Information
—z— ° 'C' O G„r.
Address or Lot #
City/Town
2.- *TYPE OF SEP IC SYSTEM*:
➢ Ej Pump ff Gravity (choose one)
***If pump sy em, attach copy of electrical permit to application***
➢ nventional System (pipe and stone system)
➢ ❑ 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)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ 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 D WC issuance)
What is the Make?
2. Owner Information
Name
Address (if different from above)
City/Town
Email address
What is the Modeh
3. Installer Information
3�1 , j �. 3
Name
Address
/'�' 13 — 7-- y
City/Tow
G . yw- q3 5V
a. Designer Information
Name
Address
City/Town
State Zip Code
Telephone Number
1 f
Name of Company
State Zip Code
Telephone Number (Cell Phone # if possible please)
Name of Company
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 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)
ba-�ibl,M
Relative to the application of
/ (Installer's name)
Dated 1
ay s ate
For plans by
And dated
With revisions dated
I understand the following obligations for management of this project:
(Engineer)
(Original ate
(Last revised date)
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior 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 (ls� 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 OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
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 simile excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understandthat work donebv 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. Determination 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 of Health staff or consmltant.
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 glans. No instructions by the homeowner, eeneral contractor. or anv other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer:
ame —
(Name — igne
(Today's Date)
L y
OF C10 TH 4ti
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Application for Septic Disposal System
Construction Permit - TOWN OF
NORTH ANDOVER, MA 01845
PAGE 2OF2
A. Facility Information continued...
5. Type of Building: ❑Residential Dwelling or ❑Commercial
B. Agreement
qlql1
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
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
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
Name Date
A anon Appr (Boa of Health Representative)
ame Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Ye , No
2. Project Manager Obligation Form Attached? Yes ✓ No
3. Pump S sy tem? If so, Attach copy ofElectrical Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approval letter, all paperwork received. Yes No
5. 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