1006 Certificate of Compliance & Septic Checklist Important:
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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
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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.
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