52 Checklists Title V Checklist
ate Received: , 3 ea/ GcW %.dc.' %
Nner: veal/, Address: 7�07` 7 / i.C7"9g�NJ l
2(
igineer: ta_cia Installer: ,//1& �.
f/Before we can schedule a Perc test we must have a copy of the trenching permit
;ued by DPW.
Give the permit a number
Mark on application form if payment provided
Give completed application and plan to agent reviewing plan
Give person submitting plan the conservation commission sign off paperwork
lans need to be discussed with conservation commission staffer and a signature obtained
for to the Board of Health issuing construction permit).
v
g/ If Local Upgrade Approval BW needs to sign off on it.
fry— Agent reviewing plan, approves Plan.
fr Before issuing construction permit ensure that the installers name is on the
plication AND that that installer has a permit with us.
BW will sign permit and stamp plans.
Contact home owner or installer that plans have been approved. Either mail them
have them come pick up plans and permit.
If LUA is needed send form 98 to owner with construction permit
Installer calls to schedule Final Inspection (they need to give proper notice that an
;pection will be needed)
Final inspection is passed and "as built" received.
Cert of compliance Issued (after as-built received).
CLOSED
ite Closed: Form updated 12/29/10
003 owNet //it
Checklist for Septic System Plan Review
0 ,Application page attached to plan
z,' PE or RS stamp, date,signature
4. //Variances to property line setback distances must have Surveyor stamp
/Legal boundaries noted
�asements noted
wellings and buildings existing or proposed noted
Location of driveway or parking areas,other impervious areas
/Location and dimensions of reserve area (new construction only)
,Visystem design calculations
Garbage grinder ye
enchmark not disturbed during construction within 75ft of facility
6staN
.h arrow
Contours
i7-'�eep hale location/s) and data ft, � L�S Ant
,PErc hole location(s) and data
vations
flames of approving authority and soil evaluator
Z/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)
W statement, if applicable-
` /ocDtion of any surface waters, rivers,vegetated wetlands
L✓Lo tion of water lines and other subsurface utilities
bserrved and adjusted groundwater elevations in vicinity of system
0.• P//rofile of system
a us plan to show location of facility, including nearest street ('xS_''/Mat-r. of constr on and specs for system
0
ye-in center line of iff-touble-washed stone
Schedule 40 PVC for trafficked areas, house to tank
• Distances noted from house to tank, etc. /
IsoI® nib-sing irproposed, design and specs of dosing system J / X rK9 C
Z.-When alternative technology is required,complete plan and spe s includingg hydraulic profile
r 1ienches preferred over beds
N • :1 slope r com_ponenp partly below groundwater level
• 3:1 sl outside of mound, toe ending 5k from property line
Local upgrade requests on the plan, all variances
Lt- Local upgrade forms attached to the application DUI ,C! s�) i., VI( c,,le I
>•-■