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Home My WebLink AboutMiscellaneous - 100 CAMPBELL ROAD 8/20/2015 i 1 1 • r i North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 100 Campbell Rd. MAP: LOT: INSTALLER: James Boraczek DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: �i �w �°"'a DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS H 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 ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port l ❑ 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 ❑ 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: m Ci" BOARD OF HEALTH " .. 1600 Osgood Street, Suite 2035 North Andover, MA 01845 978-688-9540 . APPLICATION FOR ABANDONME OF SUBSURFACE DISPOSAL SYST „$ (SEPTIC SYSTEM) Pursuant to Section 310 CMR 15.35 Of the State Environmental Code, Title Name �` 1 �� .��arc �,� ��I�, ��" Phone � P ati.� a�..a� ..� ... �� Address ((: r P" Contractor hired for work: Name -c;o .. _ .. Phone ` 7es_L .- "i"' "' 7 Address O°W// Date for scheduled abandonment The septic system at the above address has been abandoned according to Title V specifications. ignature of Contractor Method of se p tic tank abandonment(check one). O removal dfll crush other Name of Offal Hauler �_"�°�"� � �,"_, a This form must be returned to the North Andover Board of Health. PLEASE DON WRITE IN THE SPACE BELOW 'T ALT REPRESENTATIVES ONLY C1 d g I sp sting Agent ate lIr i)i P has pov ided Mis f rin for use o a r of Ha -.other fane,46 01,18,v hdonvmUan roust be mbalant,1811Y thO Offis ag Mt Provided r . usul Male okIrrr, thre rri r_ for i� rovr out"ar Wain 1, . b r� r n �k r €°�E o � i u �� vilth 310 15.35 . A. Facility 1"formation Systkin g® � J ,� eu�ura� uAN� rf �n A/ 4it ae rr/ yst rr r"Inr < &d rr,V09 'o Pumping 1, Vale f pulvlp�hg Data , . 0=4 P urn �� . ...... .... I,. a l( ) Diu Tank ''' "i h t 1:" nk rt�E P°1W� ri;etf,� 4, Effluent T cm Filter preserve Ye-IA, NO rr,was N rrnrm(P 5, Condition of System: 7 tmod inn Where,contents were B u . sirs W-4i � �� .�� ._. . Sp,Iwo FORM U - LOT RELEASE FORM i INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. t ****************************'APPLICANT FILLS OUT THIS SECTION' '" "" " *"* °*' ` APPLICANT `r—'r) ;` S I 1 o✓' Pit PHONE q f LOCATION: Assessor's Map Number . PARCEL SUBDIVISION LOT (S) STREET fG'D CL riti/]` /C b ST. NUMBER *** ***************** *******OFFICIAL USE ONLY****** * ** ****** * RECOMMENDATIONS OF TOWN .AGENTS: - CONSERVATION ADMw1OaTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED ��$EPy16N61:5'ECTOR-H TH DATE APPROVED 6 DATE REJECTED / COMMENTS N �77L;Ii �� PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE