HomeMy WebLinkAboutMiscellaneous - 317 RALEIGH TAVERN LANE 11/18/2015 PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CEIR" TIFICATE OF
COMPLIANCE
As Of: 11/18/2015
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair of an
On-Site °S
By: Jaynes Kellett
At:
317 Raleigh Tavern Lane
Map 106B Lot 144
North Andover, MA 01845
The7Issuance of this certificate shall riot be construed as a guarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
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PUBLIC HEALTH DEPARTMENT
(ornirrunily Dovololrrnont Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( constructed;( )repaired;
By: N
(Print Name)
Located at: �� 94b"
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
1 and last revised on ,1 4?—A 5— I4" ,with a design flow of
Agallons 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 1.5.000,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 Board of Health.
Bottom of Bed Inspection Date:
Engineer Representative(Signature)
And–Print Name
Final Construction Inspection Dater
Engineer Representative(Signature)
And–Print Name
Installer' : °
(Signature) Date: GI
t
�,�" And–Print Name
Engineer: �� / °�°'""'(Signature) Date:
And–Print Name
Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Wah http://www.townofnorthandover.com
North Andover Health Department
(ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 317 Raleigh Tavern Lane MAP: 106B LOT: 144
INSTALLER: James Kellett
DESIGNER: Merrimack Engineering
PLAN DATE: 5/16/14, rev 10/14/14
BOH APPROVAL DATE ON PLAN: 10/23/14
INSPECTIONS
TANK INSPECTION: 10/9/15
DATE OF BED BOTTOM INSPECTION: 10/13/15
DATE OF FINAL CONSTRUCTION INSPECTION: 1J22/15
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
N/A 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
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
® Watertightness of tank has been achieved by
visual testing
® Inlet tee installed, centered under access port
i
F7 Outlet tee installed, centered under access port
(effluent filter)
® 20" inch cover to finish grade installed over
outlet access port
® Neoprene boots around inlet & outlet
Comments: Waterline moved to be 10'-2" from septic tank.
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
® 40 Mil HDPE barrier installed
® Laterals installed and ends connected to
header (and vented if impervious material j
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: 46L x 31W. Electric line moved outside of the new leach field area
FINAL GRADE
Loamed
Seeded
Cover per plan
Comments:
DOCUMENTS NEEDED
Certification of Installation Form submitted
By engineer and signed and dated by
ngineer and installer
As-Built Plan
I
BM = 141.10
HR = 1.46
HI = 142.56
SYSTEM ELEVATIONS
ROD AS-BLT INVERT DESIGN INVERT
ELEVATION ELEV ELEV
Benchmark
Building Sewer OUT 2.74 139.47 139.5
Septic Tank IN 4.10 138.11 138.25
Septic Tank OUT 4.27 137.99 138.00
Distribution Box IN 6.20 136.01 135.90
Distribution Box OUT 6.41 135.80 135.73
Lateral 1 TOP 6.52 /6.70
Lateral 1 INVERT 135.69 / 135.51 135.68 / 135.50
Lateral 2 TOP 6.52 /6.70
Lateral 2 INVERT 135.69 / 135.51 135.68 / 135.50
Lateral 3 TOP 6.51 /6.68
Lateral 3 INVERT 135.70 / 135.53 135.68 / 135.50
Lateral 4 TOP 6.51 /6.69
Lateral 4 INVERT 135.70 / 135.52 135.68 / 135.50
Bottom of Bed 135.01 135.00
I
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 10'
® 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
rzrw� Commonwealth of Massachusetts Map-Block-Lot
107.A0126
BOARD OF HEALTH Permit No
North Andover BHP-2015-0403
----- --------------
P.I. FEE
F.I. $250.00
DISPOSAL WORKS CONSTRUCTION MIT
Permission is hereby granted James Kellett
to(Upgrade)an Individual Sewage Disposal System.
at No 317 RALEIGH TAVERN LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2015-040 Da Ober 01'2015
— -- - -------- -----------
- ------------------ --- -
Issued On: Oct-01-2015 BOARD OF HEALTH
4.45�C`�MIR _
-- ------
• �� "� Commonwealth of Massachusetts Map-Block-Lot
107.A0126
a
BOARD OF HEALTH --- - --------------
Permit No
North Andover BHP-2015-0403
FEE
$250.00
DISPOSAL, WORKS CONSTRUCTION PERMIT
Permission is hereby granted James Kellett
to(Upgrade)an Individual Sewage Disposal System.
at No 317 RALEIGH TAVERN LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2 ated October 01 2015
m m - }
--------"-"
Y I Yh rrOF mamma G4
N
Issued On: Oct-01-2015
--------------- — BOARD OF HEALTH
i
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - 'TOWN OF
NORTH ANDOVER, MA 01845 $250.00—Full Repair
$125.00 -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 system*
only the tab key X- 1
to move your Repair or replace an existing system component–What?
cursor-do not
use the return A. Facility Information
key. 1 1 l Yy
Address or Lot#
ran
City/Town
2.-*TYPE OF SEPTIC SYSTEM*: 201����
➢ ❑ Pump Gravity(choose one)
***If pump system, t�tach copy of electrical permit to application*** �k
➢ ❑Conventional System (pipe and stone system) IIN:'6�LI li Cal�l��^IAIRl h�f,4 V'
➢ ('Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
A ❑ Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes 'z 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? e t/ What is the Model.
2. Owner Information
Name
SAM-e—,
Address(if different from above)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
Name Name of Company
� 0
Address /
City/ own State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
& re
ame
e ~° Name of Company
Address
a✓c e y it c) ,6�
City/Town 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:
\ddr(rw� of septic system) For plans by t(',�d°�yY/ G2/7`�/�—
k
Relative to the application of il.'1` G ) ��t t�'
(Installer's Ilium)
And dated
Dated /C: ( zi � rt�n'� dtte
O " With revisions dated �
�
cc ay sc ate
(L,ist revised 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 priog 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 compaiv.
a. Bottom of Bed—Generally, this is the first(1y) 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: ixealtkacl � tr`1t<:>�ti tic�ftc�rtllaradc.>ver.cot ) 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 si»7ple excavation)and I am required
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. 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 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 plans. No instructions by the homeowner,general contractor,or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date)
arise—11rtnt (Name.— '.ignec:)
I
Application for Septic Disposal System IL) .-. ) - � �
Construction Permit - TOWN OF TODAY'S DATE
NORTH ANDOVER, MA 01845 $250.00—Full Repair
$125.00-Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building:)�Residential 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
Environmental Code, as we as the Local Subsurface Disposal Regulations for the Town of
North Andover. 1 understan at until a final Certificate of Compliance has been issued by
Board of Hey , the in tal system is not approved.
NOM Date
ti n A ro
,�. pp y Health Representative)
am Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Yes-Al No
3. Pump System? If so,Attach copy ofElectrical Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approvalletter, all paperwork received? Yes � �r No
Missing.
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
0
North Andover Wealth Department
Community Development Division
October 23, 2014
Kimberly and Mike Campion
317 Raleigh Tavern.Lane
North Andover, MA 01845
Re: Subsurface Sewage Disposal System Plan for 317 Raleigh Tavern Lane,Map 106B, Lot
144
Dear Mr. and Mrs. Campion:
The proposed wastewater system design plan for the above site dated May 16, 2014 submitted
September 23, 2014, with a final revision date October 14, 2014 received on October 20, 2014
has been approved.
The design has been approved for use in the construction of a replacement onsite septic system
for a 4-bedroom (max 9-room)home. This plan is generally good for 3-years from the date of
approval however, as this is for a repair system,this is reduced to 2- years.
The plan received the following local upgrade approval.
1) To allow only 1 deep hole in the disposal area rather than 2, as required by the code
2) To allow the use of a sieve analysis as a substitute to a perc test
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover. In the event an imminent health problem, such as sewage backup into the dwelling is
occurring,the North Andover Board of Health may reduce the time period for which this plan is
valid.
This approval is also subject to the following conditions:
1. Please keep the attached DEP Form 9b for your records (attached)
2. If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation, the originally issued Disposal System Construction
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
317 Raleigh Tavern Lane October 23, 2014
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit (3 10 CMR 15.020(1)).
3. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sinc 'e y,
'S san Y. Sa, er, HS/RS
ublic Health Di-ector
Encl. Form 9B
Installers list
cc: Merrimack Engineering Services
File
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 9 78.688.8476
Commonwealth of Massachusetts
City/Town of North Andover
Local Upgrade Approval
Form 9
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address
on the computer,
use only the tab Mike and Kimberly Campion
key to move your Name
cursor-do not 317 Raleigh Tavern Lane
use the return
key. Street Address
North Andover MA 01845
t� City/Town State Zip Code
2. Owner Name and Address (if different from above):
Name Street Address
City/Town State
Zip Code Telephone Number
3. Type of Facility (check all that apply):
x Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440
gpd
5. System Designer: Vladimir Nemchenok
Name PE MRS
66 Park Street Andover MA 01810
Address City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
317 Raleigh Tavern Lane Local Upgrade Approval° Page 1 of 2
I
I
Commonwealth of Massachusetts
City/Town of North Andover
Local Upgrade Approval
Farm 9
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction ft
Percolation rate
min./inch
Depth to groundwater ft
❑ Relocation of water supply well (explain):
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
® Use of only one deep hole in proposed disposal area
® Use of a sieve analysis as a substitute for a perc test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
North Andover Health Dept
Approving Authority
Susan Sawyer ,,; October 23, 2014
Print or Type Name and Title ignature Date
317 Raleigh Tavern Lane Local Upgrade Approval* Page 2 of 2
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