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Home My WebLink AboutHealth Permit # 7/6/2009 Commonwealth of Massachusetts Map-Block-Lot 104.DO107 Board of Health --------------- Pennit No 31 North Andover BHP-2-------009-06------ P.I. FEE Z. F.I. $250.00 -------------— DISPOSAL WORKS CONSTRUCTION PERMIT Pei-mission is hereby granted John-T.--Shaw,,-.Ill--- ------------------------------ -------------- ------ ------ -- --- ------- to(Repair)an Individual Sewage Disposal System. at No 209 BRIDGES LANE ---------------------------------- ------- -------------I--------—.1------ ------------------------ as shown on the application for Disposal Works Construction Permit No. BHP-2009-063 Dated July 06,2009 ------------------------ ------ ------------- Issued On: Jul-06-2009 eal 1L r ORTN -- °� � TODAY'S DATE w. tr cti Permit — TOWN 01845 $ 250.00— Full Repair p^r R.^°°'`�` $125.00 - Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use only the tab key Repair or replace an existing on-site sewage disposal system* to move your ❑ Repair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information 1� reb Address or<. Lot ---- ------- ------ --------------- -- --------------- erum City/Town 2.- TYPE OF SEPTIC SYSTEW: ❑ Pump Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) n Infiltrator or Siodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Sox Present) S.A.S. 2. Owner Information _. . . 1.:.. ...�.. .. ...yW, Name ------------ --------------—----------- ----- Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Company Address -- -- ------ -- ms City/Town State Zip Code f Telephone Number(Cell Phone#if possible please) 4. Designer Information _ r Name . --- 0' ^� Name of Company ------------ ---------------------- --- Address -- --- --- - -- City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit Page 1 of 2 e gaDRTN Ili tl ..for tlC I 'y t - �'� TODAY'S DATE * -Construction r it *^ ' NORTH ANDOVER MA d1 $ 250.00- Full Repair $125.00 - Component �CHU PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: P Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. — Name - Date d o Representative) Application A. proved By: (B �` f Health Re resent -- Na m Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee AttachedP Yes No 2. Project Manager Obligation Form Attached. Yes 1 No 3. Pump System? If so,Attach coQE ofElectrical Permit Yes-_d, es YA No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5 Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATION As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic sste m) For plans h5' u�? �ia�r��f (l ligince,7r) Relative to the application of f °>✓"/�; -"& ''x /44".r ua//.')/'' Tistaller's zr une';) And dated s"rl;nit c'a9'ei° Dated '.', " ? o 2 — (loch_s, date) With revisions dated (Last revised data) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans rp for to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (1") inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: w.c otn) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work (other tl.)an simple excaml on)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached b. Inspection of the sand and stone to be used c. Final inspection by Board of Health staff or consultant. d Installation of tan1c, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (1'oday,s Datc) w 2,07 111110 Pint) " i11'iC t;ne;cw INFILT° AT R° systems inc. This is to certify that `.J A�� has satisfactorily completed the required training program for the installation of the INFILTRATOR'leaching chamber system for on-site wastewater disposal applications, This person is certified to install the INFILTf3ATOR chamber system as set forth by the rules of the /Ll�LSJ'�u- c.deo Department of Health. STATE This certification expires on 1 Installer Signature Infiltrator Representative Signature Corporate Office P.O.Box 768 0 6 Business Park Road • Old Saybrook,CT 06475 (860)577-7000 • Fax(860)577-7001 www.infiltratorsystems.com