408 As-Built Documents NORTH FARMS ROAD
PAVED
DRIVEWAY
U.S.I. 1500 GALLON
2 COMPARTMENT
SEPTIC TANK
2
3
BRICK WALL
4
(0-BOX)
5
(INSP. PORT)
20'x 35'
LEACH FIELD
WOODEN
WALKWAY
RAISED
GARDEN
BED
FIELD MEASUREMENTS
A-1 11' 3" B-1 24'
A-2 11' 4" B-2 18' 7"
A-3 13' 11" 13-3 16' 8"
13-4 26' 10" C-4 20' 3
B-5 37' C-5 28' 3"
ROCKS
REPLACEMENT SEPTIC SYSTEM AS INSTALLED BY RANDY BAKER
EXCAVATING AT 408 NORTH FARMS ROAD, FLORENCE, MA
DECEMBER 2012 (NOT TO SCALE)
Na.
FORM 3A - CERTIFICATE OF COMPLIANCE
Fee
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /�orf/�n,nP ,ti , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Le-Complete System
The undersigned hereby certify that the Sewage Disposal System;
Constructed O, Repaired O, Upgraded (+-✓, Abandoned H
/A r,dy Aker AKCaVa+In
at: 4C8 /Ar-R 5 Road --�cm 1 fe_c/ /cc ide nce)
has been installed in accordance with the provisions of 310 C.MR 15.00 (Title 5) and the
approved design plans/as-built plans relating to application No.
dated /Vov- /O 20IL Approved Design Flow Sib (gpd)
by
Installer
Designe
41- Aa
Inspector
Date 2)ec 3 . '2012
The issuance of this permit shall not be conslrucd as a guarantee that the system will
function as designed.
No3/45 ;
— FIri LIe_cl. radfvtj Inc+ Cove-pie-fed a+ e_ oc in5pec+ion
— ePGran S l octicl toe_ huvvyed every +krea ycarS ancl
r6u-4-1eI} .(�',I{-er 5itoul/ri ha cleaned ctnvvctylly
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— e_ "As —13,, Akcs+,
On P4Cl< of $ L en-*
S„ bsraete_ in Spec-4 cc( Ivey. Zg ZofL
IMP A PPROVE, FOAM 5116
in-bp 5y5 4e»-t
40$ Norl 1. arms Road w
Massachusetts Department of Environmental Protection Site Address or MapLot Number
Bureau 12 - Per Protection-Wastewater Permitting Program
Form 12 - Percolation Test or
w
o
.. A Facility Information _
rn
Y'
1. Facility Information o
O
Ne;l 1401115/tad
or
Ownw Name //�� Map/Lot r°'..
406 (Vora, FA VMS /road p
Strut Athens a1o62_ I �n e'ne : 58 R• -°418 ra
Floreh ce_ M4 zip Code City sine V
A
Y
Percolation Test A A
Date: 3/zz/es a
Observation Hole* r-1 f-z
Depth Of Pere 40" 37" — /�� BQ /ZePvice / T
Start Pre-soak z :4.0
End Pre-soak z ;55 3tz1 a4 /4{e- oh 4.e.
Time at 12" 3 :DI
Time at 9" �P..It.A du.- 41, want." R iLt $ 41.4t 4e ueCnelS -%----"‘-------------------'
_
Time at 6° �'
Time (9"-6") -- w
Rate-Min/Inch ..— -- ca
•Mnimum al 1 Percolation tut must be performed in both the primary ores AND reserve area. a
G
a
Site Passed ❑ Site Failed ❑ -c A�
Performed By: /Bark —7-7,o"npfoi HILLTOWN ENVIRONMENTAL CONSULTING a:
P. O. BOX t28
- ... . -Waisted By ,1 .r��.laird - Meet.yv.!os_. _. .. . ...'NORTHHATFIELD MA 01066 . . ..
(413)247-5464
Comments: - 1
IC
m
DEP Form 12 Percolation Test•Page 1 or 1
PERCOLATION TEST(S)
Time.
J Time:
Observation Hole
#1
Observation Hole
#2
3' t,
Depth of Perc
L7 2
Depth of Perc
3 ^, / fz.
Start Pre-soak
Start Pre-soak
•
End Pre-soak
End Pre-soak
Time at 12"
Time at 12"
Time at 9"
Time at 9"
Time at 6"
Time at 6"
Time (9"—6")
Time(9"—6")
Rate Min /Inch
Rate Min./Inch
*minimum of 1 percolation test must be performed in both the primary area AND reserve area.
• SED ..____=
•
.FAILED'
PASSED
SITE
FAILED
Performed by
Performed by
Witnessed by
I Witnessed by
Comments:
frits//
zY7-,c-ver
Weasdaehatta
212 %tat Sheet
1a40 . 7164 01060
%C, 413-587-1214
lax 413-587-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE DESIGNING ENGINEER AND THE
SYSTEM INSTALLER
DESIGNER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V, Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage, Section 15.021 (3),the Desigmer and the Installer of a system are
required to sign this form as a condition for issuance of a Board of Health Certificate of Compliance for the
onsite septic system.
This is to certify that the onsite sewage disposal system that I desisned as: ✓ new construction
11 �- n
repair(existing system)
at » Nor+H Frrns Road on /2.3/OS DWCP number
(Date)
(Address)
has been constructed in compliance with 310 CMR 15.00, and all local requirements. Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
1 /!i/lC / !'1
OMPS or .
(Print Des, name)
Po, Box 314- Che -$er+lefI MA
(Address)
/0/17/07
(Date)
INSTALLER SIGN-OFF
This is to certify,that the onsite sewage disposal system that I installed on
(Date)
at the above-referenced address has been constructed in compliance with 310 CMR 15.00, and with the approved
plan and all local requirements.
kondv ,Baler
(P nt Insaller's name)
(Installers sigmamre)
Iv ? ,1,- toff s C
(Address)
/v - 17 - 07
(Date)
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal.
•
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