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1006 Certificate of Compliance & Septic Checklist Important: When filling out fors on the computer,use only the tab key to move your cursor-do not use the return key. 976/1/-/) Commonwealth of Massachusetts City/Town of Florence 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 hem. Before using this form, check with the local Board of Health to determine the form they use t5form3.doc•06/03 This Is to Certify that the following work on an On-Site Sewage Disposal System O Construction of a new system ❑ Repair or replacement of an existing system ❑ Repair or replacement of an existing system component Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): { DSCP Number DSCP Date Mathius Kaindi 36 North Mantle Street Hadley,MA.01035 Facility Owner l���NC P Site: Lot#2 Florence Road 77006 F --. e Street Address or Lot# 01062 Florence y: City/Town Stat Sltt Of , Zip Code Designer Information: Timothy E. Maginnis 04 Name Signatu Installer In Charles Arno Na Signature Use of this system is conditioned on compliance with the provisions set forth below'. Choice Builders Name of Cgmpanyl Date C 7C(S The issuance of this certificate shall not be construed as a guarantee that the system will function as des a_oti,G/ 44.4/v/ App mg AuMOnty Signature Date Cerfiicate of Compliance•Page 1 of 1 40 mil poly barrier (all around) 4' pvc solid pipe Existing distribution box -'E 2' force main Existing pump chamber-'D' Pumpout man-hole ('C' Existing septic tank 4' pvc solid pipe Title-5 sand Inspection port 'F' 20ft. Underground utilities E/T / / Garage G ELT 30f t: 4lf of' 4' pvc solid pipe /////////1A• / Existing / 3 bedroom / / house / 301f of 4' pvc perf pipe HWater line (ref. only) AS-BUILT DIMENSIONS ■ As-built plan Lot # 2 - Florence Road Florence, Massachusetts Owner: Mathius Kaindl 36 North Maple Street Hadley, MA. 01035 Telephone: (413) 276 - 8124 May 19, 2015 'A' to 'C' = 28'-5' '3' to 'C' = 25'-4' 'A' to 'D' = 38'-6' '8' to 'D' = 36'-10' 'A' to 'E' = 70'-6' '8' to 'E' = 76'-6' 'A' to 'F' = 70'-0' 'B' to 'F' = 88'-10' As-built plan Lot # 2 - Florence Road Florence, Massachusetts Owner: Mathius Kaindl 36 North Maple Street Hadley, MA. 01035 Telephone: (413) 276 - 8124 May 19, 2015 1011" Checklist for Septic System Plan Review F//?Nu Ro .////Application page attached to plan 6fr, � )) / or RS stamp,date, signature PGt/a5•Jk Variances to property line setback distances must have Surveyor stamp 7/* `Legal boundaries noted �/Easements noted !td Dwellings and buildings existing or proposed noted r7location of driveway or parking areas, other impervious areas ar/Spcation and dimensions of reserve area (new construction only) System design calculations //Garbage grinder, yes d" Benchmark not disturbed during construction within 75ft of facility Q North arrow 7�" .ontours �,//deep hole location(s) and data fJ gerc hole location/s) and data Elevations - /names of approving authority and soil evaluator Location of water supplies, public and private o Within 400ft of system in case of surface water and gravel-packed public water supply o Within 250ft of system in case of tubular public water supply o Within SOOft of system in case of private wells(50ft from tank) r{,/Well statement, if applicable I=/ Location of any surface waters, rivers,vegetated wetlands v_Location of water lines and other subsurface utilities Obserrved and adjusted groundwater elevations in vicinity of system ie.-Profile of system /' cocus plan to show location of facility, including nearest street CNfaterials of construction and specs for system 2r/Gas baffle V.Pipe in center line of tank 0/Double-washed stone dule 40 PVC for trafficked areas, house to tank -'/i 'Distances noted from house to tank, etc. #IIf dosing is proposed, design and specs of dosing system - /.Z When alternative technology is required, complete plan and specs including hydraulic profile e Trenches preferred over beds . C Buoyancy calculations for tanks or components partly below groundwater level 3:1 slope outside of mound,toe ending 5ft from property line • Local upgrade requests on the plan, all variances //d Local upgrade forms attached to the application z//I PAPAL— l .D.`:k 4y -i3; - ou∎ (`wc*i cr39 Col-E1-%fE- eD• q9 - t3y -oo' oc‘, -E C R . \ Y4 — i3S-aoi (`w-`3 ) low SrLA-inf e crass,R-c Ca..p iJ•Lsa-4 usu Commomveatth of Massachusetts City/Town of Septic System Installation Checklist B.Application Checklist(cont) 2 Construction Inspection a) Budding Sewer(310 CMR 15.222) Approved N/A Problem Alf waste . . . buildup sewer Basement aleck L✓ ❑ ❑ Verity by reading Pipe [2" ❑ 0 Visual 2r ❑ ❑ Visual C ❑ Visual ,t ❑ ❑ Verify by visual/tape (V ❑ ❑ Verify by casual tape [ir. ❑ ❑ Batldel material clean visual [ ❑ ❑ b) Septic Tank(310 CMR 15223) Approved WA Problem Tank is end level with 6 stone under ❑ (15228) Check with ievM ❑ Tart is required size/loading per plan Verily wpm plan L37 ❑ ❑ Inlet and oWet are at proper bastion ,,,� ❑ (15227) Verity with plan WLJ/(/ ❑ Tame is water tight(15.226) Test ❑ ❑ Outlet teen extend 6'above flow BM Verify by visuaVtape le ❑ ❑ APPcoved Mw dotal poem at outlet DEP list Er ❑ ❑ Gas bal8e led at outlet tat Visual li,. ❑ ❑ Inlet are outlet teen on center line Visa I(Q� ❑ ❑ Ts*is b.tldWed with acceptable material Visual 6 Pipe laid in continuous straight line Pipe laid on compact, firm base Cbeiouts precede ail Changes in Cleancut provided every 100 ft. .4114 - \IS 1).■fi act 121.rm Intelkban Clwe4Y 11-0SAee•an Form tame•Ply 2 of Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B.Application Checklist(cont) c) Disfritxmon Box(310 CMR 15.232) Approved WA Problem All outlet pRes at sane elevation Check by adding water [F L. ❑ Number of outlets ltt✓ Number of laterals err pee Inlet tee min. r over outlet Visual and w/tape ❑ ❑ D box set on level base Visual - ❑ ❑ Top of D box 36'max depth Visual and w/ape E ❑ ❑ D box is water-tight Add water 2 ❑ ❑ D box has a minimum of 2'thick wall and ,_/ 12'inside dimension 1} C ❑ d) Pump Chamber(310 CMR 15.231) Approved N/A Problem Tank is set level Visual and w/level I ❑ ❑ Proper volume is provided Check plan and tank [2 ❑ ❑ Float elevations set per Wan Measure w/tape L' ❑ ❑ Min.2'delivery line to 0 box Visual al : ❑ v Number of pumps: _. _. _.!__._...._._ ❑ ❑ ❑ BPecrttad pianp Provided or designers d ❑ fipOvas for alual ptanp k'1 ❑ Clxnct ptartp'equerry Q' ❑ ❑ Covers set to grate Fu^ ❑ ❑ Eternise permitprovitlad Err ❑ ❑ 6'of stone beneath chamber Visual C"l i ❑ ❑ Chamber is w ar-0Gm Tat [V ❑ ❑ Min. 7 Cover provided Vistai L7 ❑ ❑ Correct ldedrrg Provided Per Plan Visual on tank rZe". ❑ ❑ Notes: Sept%Nem seasseae tYe4Y111LeAeo•Asa Farm Na,,.•Paps 3 ere Commonwealth 0 Massachusetts City/Town of Septic System Installation Checklist a.Application Chscklht(cont) 9) Leaching Facility(310 CMR 15.240) No frozen material used indt«ng beck fill Visual No clay, tailings or stones larger than 6"for cover material Soil at bottonVsidss of excavation matches info on deep holes All mmpervlous layers removed Visual Approved N/A Problem 2- 0 ❑ 2 ❑ ❑ r ❑ ❑ ❑ No remainngglgoonaees Visual 0 ❑ deepn arks conditions match plan and 0 deep holes VIsuaUUeck plan G Verged if under impernous cover per plan (15241) 111_/ ❑ ❑ Vent is protease from precipitation and animal entry rir ❑ ❑ Cover of a minimum of 9'over leach area [Er ❑ ❑ Pipe slope equal to 0.005 Check w/transit Q' . ❑ ❑ Leach area per deeiph(t5241) 1/ ❑ ❑ Excavation is level and at required depth Visual/check plan D ❑ G Removal of 5 ft mai nel and replacement (if n fill) Visuai/Uydk can ❑ ❑ Bads fill material is atr_aPtable Visual lege ❑ ❑ Fir*contours correct per can Check with can ite ❑ ❑ Surface/subsurface mace drainage away from ❑ Fin Reds and side elopes are stark G G Distribubon lines are connected together capped, vented, a — / Impmhpble brave(1 s.255{2)) [Er"; 0 ❑ Retaining well inspected by PE " ❑ ❑ Retaining well is wsterporad n( ❑ ❑ Retaining waillbkrtier is at caned L3" depthoheight ample Steam aerwen ameba t1.cs.e30•ae Fond Nang•Par♦one Commonlreaith of Massachuse tt..001 /006 Flo re ee R041 City/Town of Septic System Installation Checklist «Or #2y B. Application Checklist(coot) 0 Leaching trenches(310 CMR 15 251,; Number of trenches. Depth of trenches. Wdth of trenches. Trench spaong per wan Stone is double-washed[3)4'to 1 4J g) Leading fields(310 CMR 15242) Length of Rald: WMth of field. Min. of 2 distribution lines Sepvation distance conforms to an Stoner is h) Leading Pits(310 CMR 15253) Number of pits. Depth of pits: Stone is double-washed J3l4'to 1WJ(15.247) Each pit has min. 1 recces*cover Piping rework and con gentian of prtYtltemters per plan i) Tight TO(310 CMR 15.260) Tank 1 sip trial with 6'More under Tarok is proper size pr pen • Pumping contract has been provided Covers to grade AN alum set at 315 tarot capacity . AN air test on separate circuit Sept Slam ItaaeN.Cassia 11 Lases•ee. -fir PLJ (15I247) it�rl iC I1` P� Visual and with level Visual w,m plan Visual Check floats by raising SW on alarm Approved N/A Problem EG ❑ ❑ G Fare Nom.•Par 5 en a Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist(cont.) p Certificate of Compliance(310 CMR 15 021} As Built Plan Submittaa Signed by Installer Signed by Designer Certificate of Compliance Issued Dam Date ow Data Notes. - 1;,)4_ k s_21S) ---> /LeitecL._ _Sys Ile _ e+ru Sle�Ls e lecAen 1 e "At, [e Gat 1v 1 I !e�bCL Q�JbJ� V f1MjIX.r wtcKf.�` crJ i Sepik sy.rm MYrasn CIrW tta ere•drr Form NYM•Pie a ore