28 Title 5 Certificate of Compliance, As-Built, System Check-Lists, 2013 Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
me
Commonwealth of Massachusetts
City/Town of Florence
Certificate of Compliance
Form 3
)70/3 45
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 here. Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ 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
Richard &Camilla Humphreys
Facility Owner
28 Morningside Drive
DSCP Date
Street Address or Lot#
Florence
City/Town
Designer Information:
Timothy E. Maginnis R.S.
Name
MA
State
01062
Zip Code
Installer lnfoirmahon:
Cliff Clark
Name/
a
No. WE
+rclsna s
Cla !�Sq1 ,
•ae•ot Rd. Williamsbur•, MA.
Name of Company
September 15, 2014
Date
Use • is system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
de- gn-d.
9, (
Approving A hority - /
SignatueG� Date
t5for3.doc•06103 Certificate of Compliance•Page 1 of 1
AS—BUILT DIMENSIONS Abandonded leaching pit
'A' to "D" = 29,_0„
"A" to "E" = 35•_0"
"B" to "D" = 40•_0"
"B' to 'E" = 49'-0"
4
��
'..,.,... LilL_J
xisting
septic tank
of 75' buffer zone -�
00
0
0
--^'„° '- - Aoro^matte
��`,,,...��--'''''
`1
mil poly barrier yh/
Ca
/ sewer pipe
pvc solid pipe
o
'F'
—
—
_
Not a reserve area
—
_
E
Not a reserve area
—
_
—
—
_
Existing distribution box("C")
B..
/ / /
/
/ /
/
/ /
4//
41b- //
/ / / / / / / /
/
/ Exis ing
/ Existing 4 bedroom /
/ garage house /
/ / / / /
I
/ / / / /
/
/ / / / l
A
Inspection ports
(D-E-F)
-
-
/
E/T
E T
/i/
W
E T
/ I
T I
W\ I
I Water line(ref. only)
W
/
iS
— � --- PAL 1--"
AS—BUILT PLAN
31ft. W 4 W
W 4 W
Ye
F ietiag
riveway_ -
E/T
/T
\ �
/
/
- - -
'/lam /7p/
\
/ Underground utilities
p/T (ref. only)
\ E
/ Richard & Camilla Humphreys
/ / 28 Morningside Drive
/1\7" Sept. 15, 2014 Florence, Massachusetts 01062
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH, M.D.
JOANNE LEVIN, M.D.
Benjamin wood,MPH,Director
Javena Mir,MPH,Health Inspector
Patricia Abbott, RN,Public Health Nurse
Heather McBride,Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587—1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health
until we receive this form signed by the Northampton Conservation Commission Staff Member.
The Conservation Commission can be reached by contacting:
0 Sarah LaValley, Conservation, Preservation and Land Use Planner
SLaValley@northamptonma.gov
Office of Planning& Development
210 Main Street, Rm. 11, City Hall
Northampton, MA 01060
Property Owner: icial 4.4,,/f/Lp45 Address:aank sie �r✓e
Engineer: ,irr /T'�„ /,A„/5 / /
Conservation Corn ion Conservation, Preservation and Land Use Planner
Date: I/3043
prorSi ui ik, r'UPil (Die CAM avid
UrmSefrai CetM44k S ovv a covcuP
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
Number
`� $ / 2 °°
Fee
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Application is hereby made for a permit to:❑ Construct a new on-site sewage disposal system
❑ Repair or replace an existing on-site sewage disposal system
Z Repair or replace an existing system component
1 Location of Facility:
28 Morningside Drive
Address or Lot/4
Florence
City/Town
2. Owner Information
Richard &Camilla Humphreys
Name
28 Morningside Drive
MA.
State
01062
Zip Code
Address(if different from above)
Florence
City/Town
3. Installer Information
Randy Baker
Name
Bridge Street
Address
Northampton
City/Town
MA
State
(413)584-3549
01062
Zip Code
Telephone Number
Randy Baker
Name of Company
4. Designer Information
Timothy E. Maginnis R.S., LSE
t5forml a.doc•06/03
Name
70 Montague Road
MA 01060
State Zip Code
(413) 586-2751
Telephone Number
Name of Company
Address
Westhampton
City/Town
MA.
State
(413) 527-5291
01027
Zip Code
Telephone Number
Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
;O/3-0
Number
$ /60
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
❑ Garbage Grinder(check if present)
B
Number of showers
2
Number of Sheets
Subsurface sewage disposal
Title of Plan
8. Description of Soil:
Loamy sand-silt loam
tern design
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
440
Gallons per Day
440
Gallons
September 24, 2013
Date of Original
Revision Date
9. Nature of Repairs or Alterations Of applicable):
Replace a failing soil absorption system. Install a new distribution box and an Infiltrator leaching
trench system. Three tenches with 10 Quick-4 Low Profile Infiltrators per trench./
10. Date last inspected:
t5form t a.doc•06/03
Date
Application far Disposal System construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
,wa-if
Number
$ /SO
Fee
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to place the system in operation until a Certificate of Compliance has been issued by this Board
of H alt&
g � � �I �__ fora
Signature Date
Application Approved By:
Name
Application Disapproved for the following reasons:
Antic
Date
ORTI IAMFTON-E@AR£Of ItEAtil
212 MAIN STREET
r1UkiMANII ON. :VIA OfubO
Conditions:
1).System Designer must inspect and verify in writing
That the sewage disposal system was installed
In accordance with the approved plans and Title 5.
2).If this is a system with the S.A.5.constructed in
Title 5 fill the System Designer must conduct a bottom
inspection of the excavated area prior to the placement
of the fill.
3).No changes can be made during construction by the
Installer without prior approval by both the System
Designer and the Board of Health Agent.
4).Other conditions
t5fonnla.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
D e-
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
7/30/ I
B. Application Checklist front)
2 Construction Inspection
a) Building Sewer(310 CMR 15 222)
All waste pipes tied into building sewer
Schedule 40 PVC 4' or cast iron
Minimum slope of 0 01-0.02
Pipe laid in continuous straight line
Pipe laid on compact. firm base
Cleanouts precede all changes in
alignmenugrade
Cleanout provided every 100 ft
Bacdill material clean
0) Septic Tank(310 CMR '5 223)
Tank is set level with 6"stone under
(15.228)
Tank is required size iloadrng per plan
Inlet and outlet we at proper location
(15 227)
Tank is water tight(15.225)
Outlet lees extend 6'above flow line
Approved filter device placed at outlet
Gas baffle installed at outlet tee
Inlet and outlet teas on center line
Basement crack
Verify by reading ppe
Visual
Visual
Visual
Verify by visuawtape
Verify by linsualltape
Visual
Check with level
Verify with plan
Verify with plan
Test
Verify by insual/tape
DEP list
Visual
Visual
Tank is batldMed with acceptable material Visual
Notes
— A/-tPpCOS
L /id '(r�/ z w
;nrt- -/4, _c._aSc- cic k. _ ..
Septic System Installaban Ch.c ku 11-09.tloc•ate
Approved N/A Problem
Ile 1 L1 0
Hoe/Z.'''.
e 1
V ❑
U✓ ❑ ❑
Approved WA Problem
V ❑ ❑
l� ❑ ❑
❑ ❑
CO ❑ ❑
ar ❑ ❑
❑ ❑
❑ ❑
•
Form rams.Peat 2 ofs
Commonwealth of Massachusetts
Cityrrown of
Septic System Installation Checklist
B. Application Checklist (cont.)
c) Distribution Box (310 CMR 15.232) Approved NIA Problem
All outlet pipes at same elevation Chace by adding water 12( L ❑
Number of outlets . Number of laterals
Inlet tee min. 1•over outlet Visual and wttape
D box set on level base Visua:
Top of D box 36'max depth Visual and w/taps
D box is water-tight Add water 'C
D box has a minimum of 7 thick wall and e
12•inside dimension i_...
d) Pump Chamber(310 CMR 15 231) Approved N/A Problem
Tank is set level Visual and wllevel ❑ % ❑
❑
Proper volume is provided Check plan and tank ❑ ❑
Float elevations set per plan Measure canape C ❑ ❑
Min. 7 delivery line to D box Visual ❑ " ❑
Number of pumps. - - ❑ ❑ ❑
Specified pump provided or designers ❑ ❑ ❑
approval for equal pump
Correct pump sequence ❑ ❑ ❑
Covers set to grade ❑ ❑ ❑
Electrical Permit provided ❑ ❑ ❑
6'of stone beneath chamber Visual ❑ ❑ ❑
Chamber is water-fight Test ❑
Min. 9"cover provided Visual ❑ ❑ ❑
Correct loading provided per plan Visual on tank ❑ ❑ ❑
Notes
Soprk System InstYYOn Checfist 11-09.GOc•dote
Form Name-Page 3 of 3
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
8. Application Checklist(cont)
e) Leaching Faclity (310 CMR 15240)
No frozen material used including back fil: Visua,
No clay, tailings or stones larger than 6•for
cover material
Soil at bottom/sides of excavation matches
info on deep holes
Alt impervious layers removed Visual
No remaining A/B horizons Vsual
Groundwater conditions match plan and
Visual/check plan
deep holes
Vented if under impervious cover per plan
(15.241)
Vent is protected from precipitation
and animal entry
Cover of a minimum of 9' over leach area
Pipe slope equal to 0 005
Leach area per design(15241)
Excavation is level and at required depth
Removal of 5 ft material and replacement
(if in fill)
Badc fill material is acceptable
Foul contours correct per plan
Surface/subsurface drainage away from
leach area
Final grade and side slopes are stable
Distribution lines are capped, vented, or
connected together
Impermeable barn&(15 255(2))
Retaining wall inspected by PE
Retaining wall is water-proofed
Retaining wallbamer is at correct
depth/height
Sett System kiaaMkpn Chen Mt 11-09 doe•an
Check w;tansit
Visual/check plan
Visual/check plan
Visual
Check with plan
Approved NIA Problem
❑
❑
Fem Name•Pepe 4 of 6
Commonwealth of Massachusetts
City/TOwn of
Septic System Installation Checklist
B. Application Checklist (cont)
0 Leaching trenches(310 CMR 15 251)
Number of trenches.
Depth of trenches'
Wdth of trenches:
Trench spacrg per an
Stoners double-washed j3/4'to 1:4.1(15.2247)
g) Leaching fields (310 CMR 15.242)
Approved
N/A Problem
J ❑
". ❑
Length of field. -- . _. _ . _._ LDf FT ❑
Wdth of field. ------ ❑'
r (1
V u
Min. of 2 distribution lines ❑ ❑
Separation distance conforms to plan ❑ ❑ ❑
Stone is double-wash(3/4'to 1W)(15 247) ❑ ❑ ❑
h) Leaching Pits(310 CMR 15.253)
Number of pits. - - - ..__..._ ❑ ❑ ❑
Depth wets: _ __._-—__..____. ❑ ❑ 0"
Stone is double-washed(3/4'to 1 W1(15.247) ❑ ❑ ❑
Each pit has min. 1 20'access aver ❑ ❑ ❑
Piping network and configuration of ❑ ❑-+ ❑
pita/d ambers par Wan
i) Tight Tank(310 CMR 15.260)
Tank is set level with 6' stone under Visual and with levet ❑ ❑ ❑
Tank is proper size per Wan Visual with plan ❑ ❑ ❑
Pumping contract has been provided ❑ ❑ ❑
Covers to grade Visual ❑ ❑ ❑
AN alarm set at 3/5 table capacity Check floats by rasing ❑ ❑ ❑
. AN alarm test on separate circuit Set off alarm ❑ ❑ ❑
Sono sytlrn eraYaoe Cheoifel 1I d9.doc•dale
Form lane•Psis 5 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
8. Application Checklist (cont)
li
Certrficate of Compliance(310 CMR 15 021)
As Built Plan Submitted
Signed by Installer
Signed by Designer
Certificate of Compliance Issued
Notes.
ale
on
Date
Sepik System Ins Marion Checklist 11-09 doc•date Faro Name•Pop 6 of 6
i3• /e
Checklist for Seotic System Plan Review ' JJ
/Application page attached to plan qG qy ^ / Vit
E or RS stamp,date, signature
Va • nces to property line setback distances must have Surveyor stamp
I boundaries noted
Easert ents noted
ellings and buildings existing or proposed noted
ation of driveway or parking areas,other impervious areas
%/vocation and dimensions of reserve area (new construction only)
E System design calculations
O Garbage grinder,yid
• Benchmark not disturbed during construction within 75ft of facility
r� North arrow
e Contours /
O Deep hole locations)and data //
• 0 Perc hole locations)a data
approving authority and soil evaluator
O 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 100ft of system in case of private wells(50ft from tank)
ell statement, if applicable
ation of any surface waters, rivers,vegetated wetlands
cation of water lines and other subsurface utilities
• serrved and adjusted groundwater elevations in vicinity of system
/Profile of system
!/{pcus plan to show location of facility, including nearest street
rC Materials of construction and specs for system
Ll P' a in center line of tank
Double-washed stone
O Schedule 40 PVC for trafficked areas, house to t;nk
G Distances noted from house to tank,etc. V
O Ifdosin; i
Wh
specs including hydraulic profile
e over e s
oyancy calculations for tanks or components partly below groundwater level
34 slope outside of mound,toe ending 5ft from property line
Q/Local upgrade requests on the plan, all variances
lacal upgrade forms attached to the application
)
■