HomeMy WebLinkAboutHealth Permit # 6/25/2014 ---- -------- ---- -- map-Block-Lot
• Commonwealth of Massachusetts 104.D0185
ttt�r� - --- ----- ---
P
BOARD OF HEALTH Pemlit No
. BHP-2014-0673
North Andover -----
FEE
P.I. ------- $250.00
F.1. ----- --- ------- - -
DISPOSAL WORKS CONSTRUCTION PERMIT
Robert K-.- Jr. ----------
Permission is hereby granted Daigle,
(Construct)an Individual Sewage Disposal System.
at No 1020 SALEM STREET -----------------------------------
as shown on the application for Dis�osal Works Construction Pernut No BHP-2014-067 Dated .-June 25,2014
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Pp 1
CSF HL-rAL'I'H
Issued On: Jun-25-201.4 ----------------
-
TODAY S DATE
Construction Permit — TOWN
ORTH $ 250.00—Full Repair
a * + 01845 $125.00 -Component
1
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 ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key i;"•'� f
to move your [❑Repair or replace an existing system component—What? Y=��
cursor-do not
use the return A. Facility Information
key. ie_l I _ —
r Address or Lot#
- - -- --- ------
eun City/Town bu,
2.a*TYPE OF SEPTIC SYSTEM*:
❑ Pump Gravity (choose one) ���"
***If pump system, attach copy of electrical permit to applic ion*** t
El Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certific tion to�mtea('i 1 typ w,it st6
❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenan a A, rrl" nt)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. fawner Information
Name
Address(if different from above)
City/Town State Zip Code
--- p — ---------
Telephone Number
3. Installer Information
�me� A Name of Company
Address
City/Town State Zip Code
� ��"
Telephone Number(Cell Phone#if possible please)
4. Desiciner Inform tion
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
; (",P c tln fir t'c o � I y t _lt�t
.m TODAY'S DATE
AlConstruction Permit — TOWN F
'T' 01845 250.00-Fu Repair
x " W
$125.00 e Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of wilding: ❑Residential Dwelling or❑Cornmercial
B. Agreement
The undersigned agrees to ensure the const and maintenance of the afore-described
on-site sewage disposal system in accord. 4 the provisions of Title 5 of the
Environmental Code, as well as the Loca! face Disposal Regulations for the Town of
North Andover, and not to place the sys peration until a Certificate of Compliance has
been issue y this Board o Hea h.
i,.., r.
_.._. Date
Name ' � e
A Ica n ApproY' y:
Board of Health Represent tive)
.
N me Date
Application Disapprov d for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Yes No
3. Pump System? If so,Attach copy ofEleco cal Permit Yes 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 OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(:kddr.c 7s cry e prot.ic,y rn)s( For plans 1>y �� M
(l ratrirte�a�7'}
, J
Relative to the application of ( d:`/I'l �� r
(Iar o;tlkc:a:', utarstne:} Ind dated z Lae
�. rtdansr csatr�:
Dated ' 4,1'°
With revisions dated a
(Last revised dame)
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 Pdor 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 OIL (or e-mail to: fzc, ltldisfagevt���f'st�ttlzst�dta��c�;.c�<,9.rWt) 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 their simple excamitio«)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 tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer, I understand that l am solely responsible for the installation of the system as per the
approved lans. No instructions by the homeowner, general contractor or any other persons shall absolve
the of this obligation.
Undersigned Licensed Septic Installer: � 'e (T rdae"S 1)ate)
-eA
7;ttnc- l lrlslt) (. anie- `~;a,gned